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

This bill would create the Community Paramedicine Act of 2018. The bill would, until January 1, 2025, authorize a local EMS agency to develop a community paramedicine program, as defined, to provide specified community paramedic services. The bill would require the authority to review a local EMS agencys proposed community paramedicine program and approve, approve with conditions, or deny the proposed program within 6 months after it is submitted by the local EMS agency. The bill would require a local EMS agency that opts to develop a community paramedicine program to, among other things, integrate the proposed program into the local EMS agencys emergency medical services plan, enter into an agreement with a community paramedicine provider for the delivery of community paramedic services within the local EMS agencys jurisdiction that is consistent with the proposed program, establish a process for training and certifying community paramedics, and facilitate and participate in any discussion between a community paramedicine provider and public or private health system participants to provide funding to support implementation of the proposed program.

The bill would create the Community Paramedicine Medical Oversight Committee to advise the authority on, and approve minimum medical protocols for, community paramedicine program specialties. The bill would require the authority to develop, in consultation with the committee, regulations that establish minimum standards for the development of a community paramedicine program. The bill would require the authority to submit an annual report on the community paramedicine programs operating in California to the relevant policy committees of the Legislature, and to post that report on its Internet Web site, beginning 6 months after the authority adopts the regulations and every January 1 thereafter for the next 5 years.

The bill would prohibit a person or organization from providing community paramedic services or representing, advertising, or otherwise implying that it is authorized to provide community paramedic services unless it is expressly authorized by a local EMS agency to provide those services as part of a community paramedicine program approved by the authority. The bill would also prohibit a community paramedic from providing community paramedic services if he or she has not been certified 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 violation of which would be a crime, the bill would impose 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 program if the local EMS agency develops a community paramedicine program.

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

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

This bill would create the Community Paramedicine Act of 2018. The bill would, until January 1, 2025, authorize a local EMS agency to develop a community paramedicine program, as defined, to provide specified community paramedic services. The bill would require the authority to review a local EMS agencys proposed community paramedicine program and approve, approve with conditions, or deny the proposed program within 6 months after it is submitted by the local EMS agency. The bill would require a local EMS agency that opts to develop a community paramedicine program to, among other things, integrate the proposed program into the local EMS agencys emergency medical services plan, enter into an agreement with a community paramedicine provider for the delivery of community paramedic services within the local EMS agencys jurisdiction that is consistent with the proposed program, establish a process for training and certifying community paramedics, and facilitate and participate in any discussion between a community paramedicine provider and public or private health system participants to provide funding to support implementation of the proposed program.

The bill would create the Community Paramedicine Medical Oversight Committee to advise the authority on, and approve minimum medical protocols for, community paramedicine program specialties. The bill would require the authority to develop, in consultation with the committee, regulations that establish minimum standards for the development of a community paramedicine program. The bill would require the authority to submit an annual report on the community paramedicine programs operating in California to the relevant policy committees of the Legislature Legislature, and to post that report on its Internet Web site, beginning 6 months after the authority adopts the regulations and every January 1 thereafter for the next 5 years.

The bill would prohibit a person or organization from providing community paramedic services or representing, advertising, or otherwise implying that it is authorized to provide community paramedic services unless it is expressly authorized by a local EMS agency to provide those services as part of a community paramedicine program approved by the authority. The bill would also prohibit a community paramedic from providing community paramedic services if he or she has not been certified 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 violation of which would be a crime, the bill would impose 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 program if the local EMS agency develops a community paramedicine program.

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

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

This bill would create the Community Paramedicine Act of 2018. The bill would would, until January 1, 2025, authorize a local EMS agency to develop a community paramedicine program, as defined, to provide specified community paramedic services. The bill would require the authority to review a local EMS agencys proposed community paramedicine program and approve, approve with conditions, or deny the proposed program within 6 months after it is submitted by the local EMS agency. The bill would require a local EMS agency that opts to develop a community paramedicine program to, among other things, integrate the proposed program into the local EMS agencys emergency medical services plan, enter into an agreement with a community paramedicine provider for the delivery of community paramedic services within the local EMS agencys jurisdiction that is consistent with the proposed program, establish a process for training and certifying community paramedics, and facilitate and participate in any discussion between a community paramedicine provider and public or private health system participants to provide funding to support implementation of the proposed program.

The bill would create the Community Paramedicine Medical Oversight Committee to advise the authority on, and approve minimum medical protocols for, community paramedicine program specialties. The bill would require the authority to develop, in consultation with the committee, regulations that establish minimum standards for the development of a community paramedicine program. The bill would require the authority to submit an annual report on the community paramedicine programs operating in California to the relevant policy committees of the Legislature beginning 6 months after the authority adopts the regulations and every January 1 thereafter for the next 5 years.

The bill would prohibit a person or organization from providing community paramedic services or representing, advertising, or otherwise implying that it is authorized to provide community paramedic services unless it is expressly authorized by a local EMS agency to provide those services as part of a community paramedicine program approved by the authority. The bill would also prohibit a community paramedic from providing community paramedic services if he or she has not been certified 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 violation of which would be a crime, the bill would impose 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 program if the local EMS agency develops a community paramedicine program.

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

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

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

This bill would declare the intent of the Legislature to enact legislation that establishes statewide guidelines for, and authorizes the implementation of, community paramedicine programs in California, as specified.

Date of Hearing: August 8, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

SBPCA Bill Id:SB 944

Author:(Hertzberg) – As Amended Ver:May 25, 2018

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

SUMMARY:

This bill, until January 1, 2025, establishes the Community Paramedicine Act of 2018 to establish state guidelines governing the implementation of community paramedicine programs (CPPs) by local Emergency Medical Service agencies (LEMSAs) in California. Specifically, this bill:

1. Establishes allowable types of CPP specialties, including short-term hospital discharge follow-up, directly observed therapy for tuberculosis, case management services to frequent emergency services user, and services to treat hospice patients or transport patients to alternate destinations in response to 911 calls.
2. Authorizes a LEMSA to develop a CPP that is consistent with this bill and EMSA regulations, and requires a local advisory committee of specified composition.
3. Requires the Emergency Medical Services Authority (EMSA) to issue regulations that establish standards governing CPPs, as specified, including training, scope of practice, paramedic certification, program approval, the collection and submission of data.
4. Requires EMSA review and approve local CPPs and submit annual reports.
5. Creates a state committee to adopt minimum medical protocols for CPP programs.
6. Establishes a number of requirements for CPPs, including that they give public agencies first right of refusal to provide the proposed specialties listed in 1), above, and allows private contracts or public-private hybrid contracts if public agencies decline to provide any or all of the proposed specialties.

FISCAL EFFECT:

1. Staff costs of approximately $400,000 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. According to the author, community paramedicine is a concept that aims to improve the efficiency and delivery of health care using trained paramedics and other health care providers to address local needs. The author notes that in November of 2014, the Office of Statewide Health Planning and Development approved an application by EMSA for the operation of specific paramedicine programs in various LEMSAs in the state. Fourteen projects were approved throughout the state, including projects in San Diego and Ventura counties, which enrolled 2,515 patients from June 2015 through September 2017. The paramedicine programs had many positive results on the communities they served. This bill will structure the implementation of local programs statewide.
2. Background. California's 33 LEMSAs provide or coordinate the provision of EMS services in their regions. EMSA oversees LEMSAs by reviewing and approving local EMS plans and provides guidance and leadership to ensure consistency and quality of EMS care statewide. Since 2015, EMSA has sponsored community paramedicine pilot projects in a dozen California communities. Community paramedicine is a fairly new and evolving health care field that allows paramedics to function outside their traditional emergency response and transport roles to facilitate appropriate use of emergency care while enhancing access to primary care for medically underserved populations. OSHPD Health Workforce Pilot Project Program, through which the community paramedicine projects were administered, allows for laws governing health care providers' scope of practice to be relaxed in order to test new health care concepts.

Independent evaluations conducted by the University of California, San Francisco, have found generally positive results from the pilots. For instance, the evaluation found no evidence of patient harm associated with implementation of the alternate destination pilot projects. Stanislaus’ "alternate destination – mental health crisis center" project enrolled 251 persons between September 2015 and September 2017. Persons enrolled received care from a mental health professional more quickly than persons with mental health needs who were not enrolled, because they did not have to first go to an ED for a medical evaluation and then be transported to a mental health crisis center. Very few enrollees (4%) had a secondary transfer to the emergency department, with no subsequent inpatient admissions.

1. Related Legislation. AB 1795 (Gipson), which was held on the Suspense File of this committee, allows specially trained paramedics to transport an individual to a designated behavioral health facility or sobering center instead of a hospital emergency department (ED).
2. Prior Legislation. AB 820 (Gipson), of the current session, allows a LEMSA to transport specified patients to a community care facility, as defined, in lieu of transportation to a hospital. AB 820 was referred to the Assembly Health Committee and not heard. AB 1650 (Maienschein), of the current session, creates the community paramedicine program within EMSA and allowed EMSA to authorize LEMSAs to participate, as specified. AB 1650 was referred to Suspense File of this committee and was not heard.
3. Support. California Professional Firefighters (CPF) is the sponsor of this bill and states that community paramedicine can leverage a trusted community resource, firefighter paramedics, to deliver important services. CPF notes CPPs will allow improved access to essential services.
   
   The American Civil Liberties Union of California supports authorizing well-trained paramedics to transport people experiencing mental health or substance use-related crises to community-based crisis stabilization centers, and notes that this bill would help to alleviate overcrowding by allowing LEMSAs to utilize trained paramedics to safely connect people with the appropriate level of care. The Steinberg Institute states that community paramedicine is a new and evolving model of community-based health care that helps facilitate more appropriate use of emergency care resources and enhance access to primary care for medically underserved populations.

The California Fire Chiefs Association and the Fire Districts Association of California support this bill, noting that community paramedicine has been piloted in several jurisdictions and has proven to provide improved services while concurrently reducing costs to local government.

1. Opposition. The Board of Registered Nursing states in opposition that the board does not believe it is appropriate to authorize paramedics, who are trained in pre-hospital emergency care and have a limited scope of practice, to perform medical clearance exams that are currently performed in EDs.

The California Hospital Association (CHA) contends, despite the bill's language stating that the Legislature intends to implement a CPP in a fashion that is respectful of the current emergency medical system and its providers, many of the bill's provisions prioritize public ambulance providers and negate the importance of the private ambulance provider industry. CHA concludes that private ambulance companies are responsible for 75% of ambulance transports in California and comprise 43% of CPP projects across the state: prioritizing public agency providers over private providers may not serve the best interests of patients throughout the state.

The California Nurses Association/National Nurses United (CNA) notes that during the review of the pilot projects, most of the data collected the first year focused on cost savings, not patient outcomes. CNA states that the end result will be cost savings for hospitals and health insurers, and a lower standard of care for the most vulnerable people in society.

EMS administrators and EMS medical directors argue this bill will erode local medical control of the EMS systems and create unnecessary impediments for innovative solutions to the delivery of healthcare by counties and their local EMS agencies. They state that among these impediments are the creation of biased community oversight committees, preferential treatment of public agencies over private entities, and the enactment of county mandated local programs that may have limited or no applicable value on a statewide basis.

1. Staff Comment. The annual reporting requirement is vague. The author may wish to clarify expectations for the annual report.

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

Date of Hearing: June 26, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SB 944

Author:(Hertzberg) – As Amended Ver:May 25, 2018

SENATE VOTE: 28-8

SUBJECT: Community Paramedicine Act of 2018.

SUMMARY: Establishes the Community Paramedicine Act of 2018 to establish state guidelines that govern the implementation of community paramedicine programs (CPPs) by local Emergency Medical Service agencies (LEMSAs) in California. Specifically, this bill:

1. States the intent of the Legislature that a CPP be designed to improve community health and be implemented in a fashion that is respectful of the current emergency medical system and its providers. States that a CPP 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. Requires a county board of supervisors, if a LEMSA develops a CPP, to establish an emergency medical care committee and to include the following members to advise the LEMSA on the development of the CPP:
   1. Two emergency room physicians practicing at an emergency department (ED) within the LEMSA's jurisdiction;
   2. Two registered nurses (RN) practicing within the LEMSA's jurisdiction;
   3. Two emergency medical technician-paramedics (EMT-P) practicing in the LEMSA's jurisdiction, at least one of whom must be employed by a public agency;
   4. The medical director for the LEMSA; and,
   5. One acute care hospital representative with an ED operating within the LEMSA's jurisdiction.
3. Defines 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 RN at the facility at all times.
   3. "Community paramedic" as a licensed paramedic who has completed the core 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.
   4. "Community paramedicine program" 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);
      3. Providing case management services to frequent emergency medical service (EMS) users;
      4. Providing services to treat hospice patients in their homes, in collaboration with the patient's hospice agency, in response to 911 calls: and,
      5. Providing patients with transport to an alternate destination facility.
   5. "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.
   6. "Public agency" as a city, county, city and county, special district, or other political subdivision of the state that provides first response services including emergency medical care.
4. Creates the Community Paramedicine Medical Oversight Committee (Oversight Committee) within EMSA to advise EMSA on, and approve minimum medical protocols for, the CPP specialties described in 3) d), above.
5. Specifies that the Oversight Committee consists of the following 11 members appointed by the Governor:
   1. Two-full-time physicians and surgeons, whose primary practice is emergency medicine, from a list of five names submitted by the California Chapter of the American College of Emergency Physicians (California ACEP);
   2. Two RNs from a list of fie names provided by the California Labor Federation;
   3. Two EMT-Ps, one EMT-P employed by a public agency from a list of three names provided by the California Professional Firefighters (CPF) and one EMT-P employed by a private ambulance company from a list of three names provided by the California Labor Federation;
   4. Two medical directors of LEMSAs from a list of five names submitted by the EMS Medical Directors Association of California (EMDAC);
   5. One LEMSA administrator from a list of three names submitted by the Emergency Medical Services Administrators Association of California (EMSAAC);
   6. One inpatient hospitalist who is a physician whose primary professional focus is the general medical care of hospitalized patients from a list of three names submitted by the California Hospital Association (CHA); and,
   7. One mental health professional from a list of three names provided by the California Psychiatric Association.
6. Requires EMSA to develop, in consultation with the Oversight Committee, regulations that establish minimum standards for the development of a CPP.
7. Requires the Commission on Emergency Medical Services to review and approve the regulations described in 6) above before EMSA adopts the regulations.
8. Requires the regulations to be based upon, and informed by, the formation and implementation of the Community Paramedicine Pilot Program under Health Workforce Pilot Project No. 173 (HWPP #173). Requires the regulations to consist of all of the following:
   1. Minimum standards for core curriculum for community paramedic training;
   2. Minimum standards for the scope of practice for each community paramedic in each program specialty as described in 3) d) above;
   3. A process for certifying a community paramedic who completes the core curriculum training;
   4. Minimum standards for approval, review, withdrawal, and revocation of a CPP;
   5. Minimum standards for collecting and submitting data to the authority to ensure patient safety that include consideration of both quality assurance and quality improvement, including, but not limited to:
      1. Intervals for community paramedicine providers, participating health facilities, and LEMSAs to submit community paramedicine data:
      2. Relevant program use data;
      3. Public posting of program analysis;
      4. Emergency medical response system feedback, including feedback from the emergency medical care committee appointed by the county board of supervisors.
      5. Consideration of ambulance patient offload times for alternate destination facilities and existing EDs, the number of patients turned away, diverted, or subsequently required to be transferred to an ED, and identification of the reasons, if the CPP utilizes an alternate destination facility;
      6. An assessment of each CPP's medical protocols or other processes; and,
      7. An assessment of the impact that implementation of a CPP has on the delivery of EMS and response times in the LEMSA's jurisdiction.
9. Requires EMSA to develop and, after approval by the Oversight Committee, adopt minimum medical protocols for each CPP specialty described in 3) d), above. Requires the protocols to be based upon, and informed by, HWPP #173, and further refinements provided by LEMSAs during the course and operation of the pilot program.
10. Requires EMSA to submit an annual report on the CPPs operating in California to the relevant policy committees of the Legislature, to post the annual report on its Internet Website, and to submit and post the first report six months after EMSA adopts regulations. Requires EMSA to report every January 1st for the next five years.
11. Allows the report to include recommendations for changes to, or the elimination of, CPP specialties that do not achieve the community health and patient goals expressed by the Legislature.
12. Requires EMSA to review a LEMSA's proposed CPP to ensure it is consistent with EMSAs regulations and the provisions of this bill.
13. Authorizes EMSA to impose conditions as part of the approval of a CPP that the LEMSA is required to incorporate into its program to achieve consistency with EMSA's regulations and the provisions of this bill.
14. Requires EMSA to approve, approve with conditions, or deny the proposed CPP within six months after it is submitted by the LEMSA.
15. Specifies that a community paramedicine pilot program approved under HWPP #173 before January 1, 2019, is authorized to continue operations until six months after the regulations described in 6) above become effective.
16. Authorizes a LEMSA to develop a CPP that is consistent with the EMSA regulations and the provisions of this bill, and submit evidence of compliance with requirements described in 17) below to EMSA for approval.
17. Requires a LEMSA that opts to develop a CPP to do all of the following:
    1. Integrate the proposed CPP into the LEMSAs EMS plan;
    2. Develop a process to select community paramedicine providers at a periodic interval of no more than 10 years; and,
    3. Enter into an agreement with a community paramedicine provider for the delivery of community paramedic services within the LEMSA's jurisdiction that are consistent with the proposed CPP. Prohibits a LEMSA 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.
18. Requires a LEMSA, if the CPP provides short-term post discharge follow-up, DOT for persons with TB, or case management to frequent 911 users, to enter into an agreement for the provision of those specialties as follows:
    1. Requires the LEMSA to solicit every public agency that is located within its jurisdiction to provide the proposed program specialties, and if a public agency agrees to provide all of those specialties, the LEMSA must enter into a written agreement to provide those specialties;
    2. Permits a LEMSA, if a public agency agrees to provide only some of the proposed community program specialties, to establish a competitive bid process to select a community paramedicine provider to deliver the specialties not provided by the public agency;
    3. Requires a LEMSA, if no public agency chooses to provide the proposed community program specialties, to establish a competitive bid process to select a community paramedicine provider to deliver the specialties; and,
    4. Requires, if the CPP provides services to hospice patients, or transports patients to alternate destination facilities, the LEMSA to do all of the following:
       1. Develop triage protocols for use by the community paramedic that will be used to determine whether a patient can be safely transported to an alternate destination;
       2. Develop triage protocols for use by the community paramedic that will be used to determine whether to transport a hospice patient, consistent with the patient's plan of care;
       3. Require the triage protocol and decision of the community 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, 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 to the patient;
       4. Enter into an agreement that continues the use of existing providers operating within the LEMSA's jurisdiction in the manner and scope in which that service has been provided by the existing provider, as specified;
       5. Certify that the alternate destination facility authorized to receive patients has adequate licensed medical staff, facilities, and equipment that comply with the requirements of the EMSA regulations and the provisions of this bill;
       6. Collaborate with the emergency medical care committee to develop medical protocols that describe when the use of an alternate destination facility is in the best interests of the patient, and upon approval of the medical director of the LEMSA, submit the protocols to EMSA. Requires the protocols to be consistent with the requirements of EMSA regulations and the provisions of this bill, and to include provisions describing the following:
          1. Qualified staff to care for the degree and severity of a patient's injuries and needs;
          2. The equipment and services available at an alternate destination facility necessary to care for patients requiring medical services; and,
          3. The time of day and any limitations that may apply for an alternate destination facility to treat patients requiring medical services.
       7. Secure an agreement with the alternate destination facility that requires the facility to notify the LEMSA 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,
       8. 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 a patient's ability to pay, and, providing that failure to do so will result in the immediate termination of use of the facility as part of the CPP.
19. Requires a LEMSA that opts to develop a CPP to:
    1. Establish a process for training and certification of community paramedics in the proposed CPP's specialties; and,
    2. Facilitate and participate in any agreements between a community paramedicine provider and public or private health system participants to provide funding to support the implementation of the LEMSA's CPP.
20. Prohibits a person or organization from providing community paramedic services, or representing, advertising, or otherwise implying that it is authorized to provide community paramedic services unless it is expressly authorized by a LEMSA to provide those services as part of a CPP approved by EMSA.
21. Allows a community paramedic to provide community paramedic services only if they have been certified to perform those services by a LEMSA and are working as an employee of an authorized community paramedicine provider.
22. Requires the disciplinary procedures for a community paramedic to be consistent with specified provisions of existing law related to EMT-Ps.
23. Prohibits entering into an agreement to be a community paramedicine provider under this bill from altering or otherwise invalidating a public agency's authority to provide or administer EMS under specified provisions of existing law related to exclusive operating areas and the continuation of local city and fire district contracts to provide emergency services.
24. Applies the limitation on liability of persons who render emergency care, including emergency services personnel, to this bill.
25. Repeals the provisions of this bill on January 1, 2025.

EXISTING LAW:

1. Establishes EMSA and grants EMSA the authority, utilizing regional and local information, to assess each EMS area for the purpose of determining the need for additional EMS services, coordination of EMS, and the effectiveness of EMS. Requires EMSA to develop planning and implementation guidelines for EMS systems which address the following components:
   1. Manpower and training;
   2. Communications;
   3. Transportation;
   4. Assessment of hospitals and critical care centers;
   5. System organization and management;
   6. Data collection and evaluation;
   7. Public information and education; and,
   8. Disaster response.
2. Requires EMSA to provide technical assistance to existing agencies, counties, and cities for the purpose of developing the components of EMS systems, and requires EMSA to adopt rules and regulations as may be reasonable and proper, and to enable EMSA to perform its duties.
3. Requires the administration of prehospital EMS by cities and fire districts providing such services as of June 1, 1980, to be retained by those cities an fire districts and to be continue at not less that the existing level until such time that a written agreement is reached between a city or fire district and a county.
4. Permits a LEMSA to create one or more exclusive operating areas in the development of a local plan, if a competitive process is utilized to select the provider or providers of the services. Specifies that no competitive process is required if the LEMSA develops or implements a local plan that continues the use of existing providers operating within a LEMSA in the manner and scope in which the services have been provided without interruption since January 1, 1981.
5. 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 review and report to the LEMSA and EMSA regarding the operations of ambulance services, emergency medical care, and first aid practices in the county.
6. 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 emergency facilities and services, emergency communications, medical equipment, personnel training, and various aspects of the EMS system; and, to make recommendations for further development of the EMS system.
7. Requires the Commission on EMS to review and approve regulations, standards and guidelines to be developed by EMSA for implementation of the EMS system and the Prehospital Emergency Medical Care Personnel Act.
8. Defines “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.
9. Establishes the HWPP Program within the Office of Statewide Health Planning and Development (OSHPD) which allows organizations to test, demonstrate, and evaluate new or expanded roles for healthcare professionals, or new healthcare delivery alternatives before changes in licensing laws are made by the Legislature.
10. Establishes, through regulation, minimum standards required for HWPPs that:
    1. Provide for patient safety;
    2. Provide qualified instructors to prepare trainees;
    3. Assure that trainees have achieved a minimal level of competence before they enter the employment/utilizations phase;
    4. Inform trainees that there is no assurance of a future change in law or regulation to legalize their role;
    5. Demonstrate that the project has sufficient staff to monitor trainee performance and to monitor trainee supervision during the employment/utilizations phase;
    6. Possess the potential for developing new or alternative roles for health care personnel or for developing a reallocation of health care task, which would improve the effectiveness of health care delivery systems; and,
    7. Demonstrate the feasibility of achieving project objectives.
11. Requires hospital EDs, under the federal Emergency Medical Treatment and Active Labor Act (EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Imposes this requirement on any hospital that participates in Medicare.
    
12. Requires, in state law, emergency services and care to be provided to any person requesting the services or care, or for whom services or care is requested, for any condition in which the person is in danger of loss of life, or serious injury or illness, at any health facility that maintains and operates and ED, when the health facility has appropriate facilities and qualified personnel available to provide the services and care. Prohibits the provision of emergency services and care from being based upon the person's ethnicity, citizenship, age, preexisting medical condition, insurance status, economic status, ability to pay, age, sex, or physical or mental disability, except to the extent that a circumstance is medically significant to the provision of appropriate medical care to the patient.
13. Establishes the Lanterman-Petris-Short (LPS) Act and declares the intent of the Legislature to end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorders, developmental disabilities, and chronic alcoholism, as well as to safeguard a person’s rights, provide prompt evaluation and treatment, and provide services in the least restrictive setting appropriate to the needs of each person.
14. Authorizes, under Section 5150 of the Welfare and Institutions Code, a peace officer, member of the attending staff of a designated facility, member of the attending staff of a designated facility, or other professional person designated by the county, upon probable cause, to take a person with a mental disorder who is a danger to self or others, or is gravely disabled, into custody (a “5150” hold) and place him or her in a designated facility.
15. Defines “designated facility” or “facility designated by the county for evaluation and treatment” as a facility that is licensed or certified as a mental health treatment facility or a hospital, as defined, and includes, but is not limited to, Acute Psychiatric Hospitals, Psychiatric Health Facilities, and a certified crisis stabilization unit.

FISCAL EFFECT: According to the Senate Appropriations Committee, to implement the bill’s provisions, EMSA identifies staffing costs of at least $290,000 General Fund in Fiscal Year (FY) 2018-19 and $276,000 General Fund in FY 2019-20, and ongoing. In addition, EMSA notes one-year contracting costs of $100,000 General Fund.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, community paramedicine is a concept that aims to improve the efficiency and delivery of health care using trained paramedics and other health care providers to address local needs. The author notes that in November of 2014, OSHPD approved an application by EMSA for the operation of specific paramedicine programs in various LEMSAs in the state. Fourteen projects were approved throughout the state, including projects in San Diego and Ventura County, which enrolled 2,515 patients from June 2015 through September 2017. The paramedicine programs had many positive results on the communities they served – the post-discharge projects reduced the 30-day readmission rate for individuals with one or more chronic conditions targeted and they saved potential costs of $1.4 million. Additionally, patients under the observed TB therapy programs were more likely to receive all their doses of TB medication than patients who were not. The author concludes that authorizing these community paramedicine concepts, with appropriate state and local oversight and input, will allow these innovative projects to continue to make the delivery of healthcare services more efficient while maintaining the highest level of patient care.
   
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. 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. Criteria for admission and support services available at the centers vary. The minimum age requirement is 18 with a length of stay from three to 14 hours per visit depending on the program and the program policy. Sobering centers do not require a commitment to abstinence to receive services although referrals for additional services are available. Transportation to the centers is most often by ambulance, sobering center operated vans, or law enforcement. San Francisco has operated a sobering center since 2003 under the San Francisco Department of Public Health, and has cared for 12,000 individuals with over 54,000 visits. The sobering center is a nurse-led program available 24/7 with registered nurse staffing, patient care assistants, medical assistants, and social workers providing case management.
   2. 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 EMTALA and state law is required to provide emergency medical services to any individual who presents and requires emergency medical attention. In addition to inpatient facilities, counties can designate certain outpatient facilities under the LPS Act, such as crisis stabilization units. A crisis stabilization unit is generally open 24 hours a day, seven days a week, and provides up to 23 hours of psychiatric urgent care intended to stabilize a patient suffering from psychiatric distress, with the goal of stabilizing the patient and avoiding the need for inpatient care.
      
   3. 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.
      
   4. 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.
      
   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.

As noted in 3) above in existing law above, the definition of advanced life support requires that 911 callers are taken to an acute care hospital having a basic or comprehensive ED. The location where paramedics can practice, i.e., at the scene of a medical emergency, during transport to an ED, during inter-facility transfer, and while in the ED until responsibility is assumed by hospital staff is also specified in code and regulations. Most other scope of practice definitions specify skills and activities but not location. In transporting patients to EDs, paramedics triage patients using protocols developed by their LEMSA to determine which location is best suited for the patient, for example, an ED with a trauma center, or a hospital specializing in treating stroke victims.

• 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.  
        
     6. 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. CPF is the sponsor of this bill and states that community paramedicine can leverage a trusted community resource, firefighter paramedics, to deliver important services. CPF notes that when communities are asked who they trust firefighters are always ranked among the most trustworthy leaders in each community, making them well positioned to utilize existing resources and apply expanded protocols developed by medical and behavioral health experts to improve patient care throughout their communities. CPF points out that firefighters serve at strategically placed firehouses throughout each community 24/7. CPPs will allow improved access to essential services.
   
   The American Civil Liberties Union of California support authorizing well-trained paramedics to transport people experiencing mental health or substance use-related crises to community-based crisis stabilization centers, and notes that this bill would help to alleviate overcrowding by allowing LEMSAs to utilize trained paramedics to safely connect people with the appropriate level of care. The Steinberg Institute states that community paramedicine is a new and evolving model of community-based health care that helps facilitate more appropriate use of emergency care resources and/or enhance access to primary care for medically underserved populations.
   
   The California Fire Chiefs Association and the Fire Districts Association of California support this bill, noting that community paramedicine has been piloted in several jurisdictions and has proven to provide improved services while concurrently reducing costs to local government.
2. OPPOSITION. The Board of Registered Nursing states in opposition that the Board does not believe it is appropriate to authorize paramedics who are trained in pre-hospital emergency care and have a limited scope of practice to perform medical clearance exams that are currently performed in EDs. CHA states that the California emergency services system benefits from having a lead statewide authority coordinating and assisting decentralized local agencies that can successfully incorporate the unique local and regional issues to ensure that optimal patient care is provided. CHA contends that despite the bill's language stating that the Legislature intends to implement a CPP in a fashion that is respectful of the current emergency medical system and its providers, many of the bill's provisions prioritize public ambulance providers and negate the importance of the private ambulance provider industry. CHA concludes that private ambulance companies are responsible for 75% of ambulance transports in California and comprise 43% of CPP projects across the state: prioritizing public agency providers over private providers may not serve the best interests of patients throughout the state.
   
   The California Nurses Association/National Nurses United (CNA) notes that during the review of the pilot projects, most of the data collected the first year focused on cost savings, not patient outcomes. CNA states that the end result will be cost savings for hospitals and health insurers, and a lower standard of care for the most vulnerable people in society. CNA contends that California faces a shortage of firefighters and it is not clear why dually certified firefighter paramedics should be diverted from their primary role in protecting California from environmental disasters such as California has experienced during the past fire season. CNA also notes that there are 400,000 licensed RNs in California, 100,000 Licensed vocational Nurses and more than 75,000 behavioral health licensed professionals who can provide direct acute and chronic care to patients in all settings.
   
   EMSAAC and EMDAC state that this bill will erode local medical control of the EMS systems and create unnecessary impediments for innovative solutions to the delivery of healthcare by counties and their local EMS agencies. EMSAAC and EMDAC state that among these impediments are the creation of biased Community Oversight Committees, preferential treatment of public agencies over private entities, and the enactment of county mandated local programs that may have limited or no applicable value on a statewide basis.
3. RELATED LEGISLATION. AB 1795 (Gipson) Authorizes a LEMSA to submit, as part of its EMS plan, a plan to transport specified patients who meet triage criteria to a behavioral health facility or a sobering center, as defined. Authorizes a city, county, or city and county to designate, and contract with, a sobering center to receive patients, and would establish sobering center standards. Requires EMSA to adopt guidelines for the triage criteria and assessment procedures by July 1, 2020, and requires EMSA to annually analyze administration of local plans and issue a report, as specified. AB 1795 was held on the Assembly Appropriations Committee suspense file.
4. PREVIOUS LEGISLATION.
   1. AB 820 (Gipson) of 2017 would have allowed a LEMSA to transport specified patients to a community care facility, as defined, in lieu of transportation to a GACH. AB 820 was held in the Assembly Health Committee.
      
   2. AB 1650 (Maienschein) of 2017 would have created the CPP within EMSA and allowed EMSA to authorize LEMSAs to participate in the CPP to provide services utilizing EMT-P personnel for the delivery of medical care, as specified. AB 1650 was held in the Assembly Appropriations Committee.
      
   3. AB 451 (Arambula) of 2017 would have required an APH, and a psychiatric unit of a GACH, to comply with provisions of law requiring emergency services to be provided regardless of a patient’s ability to pay in order to treat a psychiatric emergency medical condition, as defined, regardless of whether the facility operates an ED, consistent with provisions of law requiring patients with emergency medical conditions to be stabilized, including a transfer when necessary to appropriate facilities. AB 451 was held in the Senate Appropriations Committee.
5. SUGGESTED AMENDMENTS.
   1. As currently drafted, this bill requires the county level emergency medical care committee to include two EMT-Ps practicing in the LEMSA's jurisdiction, at least one of whom must be employed by a public agency. LEMSA's in rural areas do not all have public agencies that employ EMT-Ps, often the only provider of prehospital emergency care is a private ambulance company. The Committee may wish to amend the bill to clarify that the committee will include an EMT-P employee by a public agency, except in local EMS agency jurisdictions where no public agency employs an EMT-P.
      
      
   2. As currently drafted this bill creates a new Oversight Committee within EMSA to advise EMSA on, and approve minimum medical protocols for the CPP specialties, with 11 members appointed by the Governor.
      
      Existing law 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 emergency facilities and services, emergency communications, medical equipment, personnel training, and various aspects of the EMS system; and, to make recommendations for further development of the EMS system. The Oversight Committee that this bill seeks to establish and the existing Commission on EMS have overlapping qualifications, as follows: full time physicians whose primary practice is emergency medicine, RNs, local EMS administrators, and EMT-Ps.

Given the overlap of the two entities, the Oversight Committee established by this bill appears unnecessary and duplicative. The Committee may wish to amend the bill to delete the Oversight Committee, and instead add to or revise the membership of the EMS Commission to include members with experience in behavioral health issues, TB treatment, and providing post discharge followup care.

REGISTERED SUPPORT / OPPOSITION:

Support

California Professional Firefighters (sponsor)

American Civil Liberties Union

California Chapter of the American College of Emergency Physicians

California Fire Chiefs Association/Fire Districts Association of California

City of Murrieta

County of Santa Clara

Long Beach Firefighters, Local 372

Los Angeles County Fire Fighters Local 1014

Steinberg Institute

United Firefighters of Los Angeles City, IAFF Local 112

Opposition

911 Ambulance Provider Medi-Cal Alliance

Board of Registered Nursing

California Ambulance Association

California Association for Health Services at Home

California Hospice & Palliative Care Association

California Hospital Association

California Nurses Association/National Nurses United

County of Fresno
Emergency Medical Services Administrators Association of California

Emergency Medical Services Medical Directors Association of California

Medical Board of California

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

 THIRD READING  

Bill No: SB 944

Author:

:

Vote:

SENATE HEALTH COMMITTEE: 8-0, 4/18/18

AYES: Hernandez, Nguyen, Leyva, Mitchell, Monning, Newman, Pan, Roth

NO VOTE RECORDED: Nielsen

SENATE JUDICIARY COMMITTEE: 6-1, 4/24/18

AYES: Jackson, Anderson, Hertzberg, Monning, Stern, Wieckowski

NOES: Moorlach

SENATE APPROPRIATIONS COMMITTEE: 4-0, 5/25/18

AYES: Lara, Bradford, Hill, Wiener

NO VOTE RECORDED: Bates, Beall, Nielsen

SUBJECT:

SOURCE: California Professional Firefighters

DIGEST:

This bill enacts the Community Paramedicine Act of 2018, which permits local emergency medical services agencies, with approval by the Emergency Medical Services Authority, develop a program to provide community paramedic services in or more of the following five 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.

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 review and report to the local EMS agency and EMSA regarding the operations of ambulance services, emergency medical care, and first aid 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 emergency facilities and services, emergency communications, medical equipment, personnel training, and 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 Act of 2018, and states the intent of the Legislature that, among other things, an alternative destination facility participating as part of an approved community paramedicine program will always be staffed by a higher medical authority, that the delivery of community paramedic services is a public good and is complementary to the existing emergency response system, and that whenever possible, public agencies that provide first response services should delivery care under a community paramedicine program.
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 paramedic 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 postdischarge followup for persons recently discharged from a hospital due to a serious health condition;
   2. Providing directly observed therapy to persons with tuberculosis;
   3. Providing case management services to frequent EMS users;
   4. Providing services to treat hospice patients in their homes, in collaboration with the patient’s hospice agency, in response to 911 calls; and,
   5. Providing patients with transport to an alternate destination facility.
3. 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;
   4. “Community paramedic” is a licensed paramedic who has completed the core curriculum for community paramedicine as described in this bill, has received certification in one or more of the community paramedicine program specialities 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; and,
   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.
4. Establishes the Community Paramedicine Medical Oversight Committee (Oversight Committee) within EMSA to advise the EMSA on, and approve minimum medical protocols for, the community paramedicine program specialties specified in 2) above. Requires the Oversight Committee to consist of 11 members as specified, all appointed by the Governor.
5. Requires EMSA to develop, in consultation with the Oversight Committee, regulations that establish minimum standards for the development of a community paramedicine program, and requires the Commission on EMS to review and approve the regulations before EMSA adopts them.
6. Requires the regulations developed pursuant to 5) above to be based upon, and informed by, the formation and implementation of the Community Paramedicine Pilot Program under HWPP #173 (HWPP #173), and to consist of certain minimum standards, as specified.
7. Requires EMSA to develop, and after approval by the Oversight Committee, establish minimum medical protocols for each community paramedicine program specialty described in 2) above. Requires these protocols to be based upon, and informed by, the formation and implementation of HWPP #173, and further refinements provided by local EMS agencies during the course and operation of HWPP #173.
8. Requires EMSA to submit an annual report on the community paramedicine 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 specified in 5) above, and every January 1 thereafter for the next five years. Permits this report to include recommendations for changes to, or the elimination of, the community paramedicine program specialties that do not achieve the community health and patient goals of this bill. Repeals these reporting provisions six years after the authority adopts the regulations specified in 5) above.
9. Permits a local EMS agency to develop a community paramedicine program that is consistent with EMSAs regulations and the provisions of this bill and submit it to EMSA for approval. Requires EMSA to review a local EMS agency’s proposed community paramedicine program to ensure it is consistent with EMSAs regulations and the provisions of this bill.
10. Requires EMSA to approve, approve with conditions, or deny the proposed community paramedicine 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 the provisions of this bill.
11. Permits a community paramedicine pilot program approved under HWPP #173 before January 1, 2019, to continue operations until six months after the regulations described in 5) above become effective.
12. Requires a local EMS agency that opts to develop a community paramedicine program to do all of the following:
    1. Integrate the proposed community paramedicine program into the local EMS agency’s EMS plan, as defined;
    2. Develop a process, consistent with this bill, to select community paramedicine providers at a periodic interval of no more than ten years; and,
    3. Enter into an agreement with a community paramedicine provider for the delivery of community paramedic services within the local EMS agency’s jurisdiction that are consistent with the proposed community paramedicine program. 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.
13. Requires the local EMS agency, if the community paramedicine program provides the program specialties described in 2) above (except for alternate destination and services to hospice patients), to enter into an agreement for the provision of those specialties according to the following:
    1. Requires a local EMS agency to solicit every public agency that is located within its jurisdiction to provide the proposed community program specialties, and if a public agency agrees to provide all of those specialties, requires the local EMS agency to enter into a written agreement with the public agency to provide those specialties;
    2. Permits the local EMS agency, if a public agency agrees to provide only some of the specialties, to establish a competitive bid process to select a community paramedicine provider to deliver the specialties not provided by the public agency; and,
    3. Requires the local EMS agency, if no public agency chooses to provide the proposed community program specialties, to establish a competitive bid process to select a community paramedicine provider to deliver the specialties.
14. Requires a local EMS agency, if the community paramedicine program provides the specialty of transport to an alternate destination facility, or the specialty of services to hospice patients, to do all of the following:
    1. Develop triage protocols for use by the community paramedic that will be used to determine (a) whether a patient can be safely transported to an alternate destination, or (b) whether to transport a hospice patient. Prohibits the triage protocol, or the decision of the community paramedic, from being based upon or affected by the patient’s ethnicity, citizenship, age, 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.
    2. Enter into an agreement that continues the use of existing providers operating within the local EMS agency’s jurisdiction in the manner and scope in which that service has been provided by the existing provider, as specified;
    3. Certify 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;
    4. Collaborate with the emergency medical care committee to develop medical protocols that describe when the use of an alternate destination facility is in the best interests of the patient and, upon approval of the medical director of the local EMS agency, submit the protocols to EMSA. Requires the medical protocols to be consistent with the requirements of EMSA’s regulations, and requires the protocols to include provisions describing the qualified staff to care for the degree and severity of a patient’s injuries and needs, the equipment and services available at an alternative destination facility necessary to care for patients, and time of day and any limitations that may apply for an alternate destination facility;
    5. 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,
    6. 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 community paramedicine program.
15. Requires a local EMS agency that opts to develop a community paramedicine program to establish a process for training and certification of community paramedics in the proposed community paramedicine program’s specialties, and to facilitate and participate in any agreements between a community paramedicine provider and public or private health system participants to provide funding to support implementation of the local EMS agency’s community paramedicine program.
16. 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.
17. 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.
18. 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.
19. Requires the disciplinary procedures for a community paramedic to be consistent with specified provisions of existing law related to EMT-Ps.
20. 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.
21. Sunsets the provisions of this bill on January 1, 2025.

Comments

1. Author’s statement. According to the author, community paramedicine is a concept that aims to improve the efficiency and delivery of health care using trained paramedics and other health care providers to address local needs. In November of 2014, OSHPD approved an application by EMSA for the operation of specific paramedicine programs in various local EMS agencies in the state. Fourteen projects were approved throughout the state, including projects in San Diego and Ventura County, which enrolled 2,515 patients from June 2015 through September 2017. The paramedicine programs had many positive results on the communities they served – the post-discharge projects reduced the 30-day readmission rate for individuals with one or more chronic conditions targeted and they saved potential costs of $1.4 million. Additionally, patients under the observed tuberculosis (TB) therapy programs were more likely to receive all their doses of TB medication than patients who were not. Authorizing these community paramedicine concepts, with appropriate state and local oversight and input, will allow these innovative projects to continue to make the delivery of healthcare services more efficient while maintaining the highest level of patient care.
2. Paramedic training and scope of practice. Under regulations adopted by EMSA, paramedic training consists of a minimum of 1090 hours. These training hours are divided into: 450 hours of didactic instruction and skills laboratories; 160 hours of hospital clinical training; and, a field internship of 480 hours. During the field internship, the paramedic student is required to have a minimum of 40 advanced life support patient contacts, which is defined as the student performance of one or more of advanced life support skills. Following the training program, paramedic applicants are required to pass both a written and practical examination. In addition to state licensure by EMSA, paramedics are required to have “local accreditation” by a local EMS agency in order to practice as a paramedic within that jurisdiction. Under their scope of practice, a paramedic is authorized to perform specified advanced life support procedures and administer specified medications while at the scene of a medical emergency or during transport or during interfacility transfer, or while working in a small and rural hospital, as specified. Procedures that paramedics are authorized to perform include utilizing and monitoring electrocardiograms, defibrillation, adult endotracheal intubation, instituting intravenous catheters or other IV lines in peripheral veins, and monitoring and administering medications through pre-existing vascular access. Regulations specify a list of 25 medications that a paramedic is authorized to administer.
3. Background on HWPP #173. In November of 2014, OSHPD approved an application from EMSA to establish HWPP #173, to test different concepts of community paramedicine. Initially, HWPP #173 encompassed 13 sites testing the following six concepts:
4. Post-Discharge Short-Term Follow-Up, intended to provide home-based follow up care to people recently discharged from a hospital due to a chronic condition;
5. Frequent EMS Users, intended to provide case management to frequent 911 callers and frequent visitors to emergency departments by connecting them with primary care, behavioral health, housing, and social services;
6. Directly Observed Therapy for Tuberculosis, where the paramedic dispensed medication and observed patients taking them to assure effective treatment;
7. Hospice, where paramedics, in response to 911 calls, collaborated with hospice agency nurses, patients, and family members to treat patients in their homes, according to their wishes, instead of transporting to an emergency department;
8. Alternate Destination – Behavioral Health, where paramedics, in response to 911 calls, offer to transport people who have behavioral health needs but no emergency medical needs to a mental health crisis center instead of an emergency department; and,
9. Alternate Destination – Urgent Care, where paramedics, responding to 911 calls, offer people with low-acuity medical conditions transport to an urgent care center instead of an emergency department.

A seventh concept began enrolling patients in February of 2017: San Francisco’s Alternate Destination – Sobering Center, where paramedics, in response to 911 calls, offer people who are acutely intoxicated but do not have acute medical or mental health needs transport directly to a sobering center for monitoring instead of an emergency department. Since its initial approval for a one-year period, HWPP #173 has been renewed three times. The last renewal was in November of 2017, and unless renewed again, it is scheduled to end on November 14, 2018. Nine new project sites were approved to begin enrolling patients this year, while four project sites have closed, including all three Alternate Destination – Urgent Care project sites, which were closed due to low enrollment.

Paramedics who wished to participate in HWPP #173 were required to have had at least four years of experience, be volunteers, and be sponsored by their local EMS agency. A core curriculum was developed that OSHPD reviewed and approved, which was adapted from the Paramedic Foundation’s National Community Paramedic Curriculum. The curriculum specified 48 hours of didactic, classroom-based instruction, and 48 hours of clinical, hands-on training. Additionally, community paramedic trainees were required to complete 56 hours of study outside of the classroom. There were 77 paramedics who completed the core curriculum and made up the initial cohort of community paramedics, although others have since completed the training. Collectively, HWPP #173 enrolled 2,515 patients from June 2015 through September 2017 across all project sites (the most recent data available). The post-discharge projects enrolled the largest number of patients and the tuberculosis project had the smallest.

For a discussion of the results of the six concepts from HWPP #173 incorporated into this bill, see the Senate Health Committee analysis.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Committee on Appropriations:

To implement the bill’s provisions, the EMSA identifies staffing costs of at least $290,000 General Fund in Fiscal Year (FY) 2018-19 and $276,000 General Fund in FY 2019-20, and ongoing. In addition, the department notes one-year contracting costs of $100,000 General Fund.

SUPPORT: (Verified 5/24/18)

California Professional Firefighters (source)

American Civil Liberties Union

California Chapter of the American College of Emergency Physicians

California Fire Chiefs Association/Fire Districts Association of California

City of Murrieta

County of Santa Clara

Local Health Plans of California

Long Beach Firefighters, Local 372

Los Angeles County Fire Fighters Local 1014

United Firefighters of Los Angeles City, IAFF Local 112

OPPOSITION: (Verified 5/24/18)

California Ambulance Association

California Association for Health Services at Home

California Hospice & Palliative Care Association

California Nurses Association/National Nurses United

Emergency Medical Services Medical Directors Association of California

Medical Board of California

One Individual

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 Local Health Plans of California (LHPC) writes in support that recent pilot programs have demonstrated the value of leveraging trusted community resources, like firefighters, mental health facilities and sobering centers, for improving and expanding our health care system. LHPC states that this bill would provide a reasonable, thoughtful pathway for expanding these important programs.

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 is not the appropriate bill to authorize community paramedic services. CAA states that this bill restricts private ambulance companies from being able to provide community paramedic services. CAA states that this bill imposes new mandates on local EMS agencies and weakens local control. According to CAA, this bill advances the authority and control of fire departments and fire districts, while sacrificing coordinated EMS services for the public.

The California Nurses Association/National Nurses United (CNA) states in opposition that this bill threatens patient safety by authorizing the use of fire and ambulance paramedics to provide healthcare services currently provided by physicians, registered nurses, and licensed behavioral health professionals. CNA states that under HWPP #173 paramedics are undertaking care with limited training, not nearly enough for them to acquire the level of expertise and skill needed. For example, CNA states that in that case of the sobering center pilot, alternate destination paramedics receive only eight additional hours of training. CNA argues that patient safety should be paramount, rather than cost savings. With regard to the specific projects, CNA argues that the number of enrollees in many of the projects was very low, the patient population did not reflect California’s diversity, the evaluation of the projects contained selective use of data, and that the high proportion of Medi-Cal users among enrollees indicated a tendency toward a two-tiered system of care. 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 including hospice care within a community paramedicine program, this bill is inserting non-hospice and non-hospice licensed individuals into the care of an individual who has elected hospice care and has foregone curative treatment. In addition, CHPCA states that this bill raises questions of liability and responsibility for payment within the hospice capitated system.

Prepared by:

5/28/18 9:49:12

**** END ****

SENATE COMMITTEE ON

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

SB 944 (Hertzberg) - Community Paramedicine Act of 2018

Bill Summary:

Senate Bill 944 would establish the Community Paramedicine Act of 2018, which permits local emergency medical services agencies, with approval by the Emergency Medical Services Authority (EMSA), develop a program to provide community paramedic services in or more of the following five specialties: (1) providing short-term post-discharge follow-up; (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.

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on May 25, 2018

Fiscal Impact:

To implement the bill’s provisions, the Emergency Medical Services Authority identifies staffing costs of at least $290,000 General Fund in Fiscal Year (FY) 2018-19 and $276,000 General Fund in FY 2019-20, and ongoing. In addition, the department notes one-year contracting costs of $100,000 General Fund.

Committee Amendments:

The committee amendments clarify intent.

-- END --

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

SB 944 (Hertzberg) - Community Paramedicine Act of 2018

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

Bill Summary:

Senate Bill 944 would establish the Community Paramedicine Act of 2018, which permits local emergency medical services agencies, with approval by the Emergency Medical Services Authority (EMSA), develop a program to provide community paramedic services in or more of the following five specialties: (1) providing short-term post-discharge follow-up; (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. In addition, EMSA must review a local emergency medical services (EMS) agency

Fiscal Impact:

• To implement the bill’s provisions, the Emergency Medical Services Authority identifies staffing costs of at least $290,000 General Fund in Fiscal Year (FY) 2018-19 and $276,000 General Fund in FY 2019-20, and ongoing. In addition, the department notes one-year contracting costs of $100,000 General Fund.

Background:

The Office of Statewide Health Planning and Development (OSHPD) operates the Health Workforce Pilot Project program, which provides the legal framework for healthcare organizations to demonstrate, test, and evaluate new or expanded roles for healthcare professionals.

In 2014, the OHSPD approved a pilot project, sponsored by the Emergency Medical Services Authority (EMSA). The project, Health Workforce Pilot Project #173 was authorized to test, demonstrate, and evaluate the practice of “Community Paramedicine” in the following areas, among others:

• Post-Discharge Short-Term Follow-Up, intended to provide home-based follow up care to people recently discharged from a hospital due to a chronic condition;
• Frequent EMS Users, intended to provide case management to frequent 911 callers and frequent visitors to emergency departments by connecting them with primary care, behavioral health, housing, and social services;
• Directly Observed Therapy for Tuberculosis, where the paramedic dispensed medication and observed patients taking them to assure effective treatment;
• Hospice, where paramedics, in response to 911 calls, collaborated with hospice agency nurses, patients, and family members to treat patients in their homes, according to their wishes, instead of transporting to an emergency department;
• Alternate Destination – Behavioral Health, where paramedics, in response to 911 calls, offer to transport people who have behavioral health needs but no emergency medical needs to a mental health crisis center instead of an emergency department; and,
• Alternate Destination – Urgent Care, where paramedics, responding to 911 calls, offer people with low-acuity medical conditions transport to an urgent care center instead of an emergency department.

A seventh concept began enrolling patients in February of 2017: San Francisco’s Alternate Destination – Sobering Center, where paramedics, in response to 911 calls, offer people who are acutely intoxicated but do not have acute medical or mental health needs transport directly to a sobering center for monitoring instead of an emergency department. Since its initial approval for a one-year period, HWPP #173 has been renewed three times.

Unless renewed again, the pilot is scheduled to end in November 2018. Nine new project sites were approved to begin enrolling patients this year, while four project sites have closed, including all three Alternate Destination – Urgent Care project sites, which were closed due to low enrollment.

Paramedics who wished to participate in the pilot were required to have had at least four years of experience, be volunteers, and be sponsored by their local EMS agency. A core curriculum was developed that OSHPD reviewed and approved, which was adapted from the Paramedic Foundation’s National Community Paramedic Curriculum. The curriculum specified 48 hours of didactic, classroom-based instruction, 48 hours of clinical, hands-on training, and 56 hours of study outside of the classroom.

77 paramedics completed the core curriculum and made up the initial cohort of community paramedics, and more have completed the training. The community paramedicine pilot enrolled 2,515 patients from June 2015 through September 2017, across all project sites, with the post-discharge projects enrolling the largest number of patients and the tuberculosis project, the smallest.

This bill: Senate Bill 944 establishes the Community Paramedicine Act of 2018, and provides in legislative intent, among other provisions, that an alternative destination facility participating as part of an approved community paramedicine program will always be staffed by a higher medical authority, that the delivery of community paramedic services is a public good and is complementary to the existing emergency response system, and that whenever possible, public agencies (defined as city, county, special district, or other political subdivision of the state that provides first response services, including emergency medical care that provide first response services) should delivery care under a community paramedicine program.

The bill authorizes the following community paramedic services:

• Short-term post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition;
• Directly observed therapy to persons with tuberculosis;
• Case management services to frequent EMS users;
• Hospice services to treat patients in their homes; and,
• Transport to an alternate destination facility.

State Administration. SB 944 requires the Community Paramedicine Oversight Committee, comprised of 11 members appointed by the Governor, to advise EMSA on and approve minimum medical protocols. EMSA must develop regulations that establish minimum standards for the development of a community paramedicine program, and requires the Commission on EMS to review and approve the regulations before EMSA adopts them.

The bill requires that if a local emergency services agency develops a community paramedicine program, the program just include all of the following:

• Minimum standards and core curriculum for community paramedic training;
• Minimum standards for the scope of practice for each community paramedicine program specialty described in 2) above;
• A process for certifying a community paramedic who completes the core curriculum training;
• Minimum standards for approval, review, withdrawal, and revocation of a community paramedicine program; and,
• Minimum standards for collecting and submitting data to the authority to ensure patient safety that include consideration of both quality assurance and quality improvement.

In addition, the bill requires EMSA to develop, and after approval by the Oversight Committee, establish minimum medical protocols for each community paramedicine program specialty.

Timing. Under the bill, a community paramedicine pilot program approved under HWPP #173 before January 1, 2019, to continue operations until six months after the regulations described in 5) above become effective.

Local Administration. SB 944 requires a local EMS agency that opts to develop a community paramedicine program to do integrate the proposed community paramedicine program into the local EMS agency’s EMS plan, as defined; develop a process, consistent with this bill, to select community paramedicine providers at a periodic interval of no more than ten years; and, enter into an agreement with a community paramedicine provider for the delivery of community paramedic services within the local EMS agency’s jurisdiction that are consistent with the proposed community paramedicine program.

Under the bill, if a community paramedicine program provides emergency medical services program specialties, the local EMS agency must develop triage protocol for a community paramedic to safely transport to an alternate destination or hospice care. In addition, the triage protocol and decision to transport must not be based on a patient’s ethnicity, citizenship, age, preexisting medical condition, insurance status, or ability to pay for medical services.

Exclusive operating areas. The bill 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. The bill requires a local EMS agency to provide right of first refusal to every public agency that is located within its jurisdiction to provide the community program specialties.

Training and certification. The bill requires a local EMS agency that opts to develop a community paramedicine program to establish a process for training and certification of community paramedics in the propose community paramedicine program’s specialties.

Disciplinary action. The bill requires the disciplinary procedures for a community paramedic to be consistent with specified provisions of existing law related to EMT-Ps.

Liability. The bill 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.

Legislative reporting requirement. The bill requires EMSA to submit an annual report on the community paramedicine to the relevant policy committees in the legislature at specified intervals, and repeals the reporting requirement six years after EMSA adopts the regulations.

Related Legislation:

• AB 1795 (Gipson) authorizes a local EMS agency to submit, as part of its EMS plan, a plan to transport specified patients who meet triage criteria to a behavioral health facility or a sobering center, as defined. Authorizes a city, county, or city and county to designate, and contract with, a sobering center to receive patients, and would establish sobering center standards. Requires EMSA to adopt guidelines for the triage criteria and assessment procedures by July 1, 2020, and requires EMSA to annually analyze administration of local plans and issue a report, as specified.
• AB 820 (Gipson, 2017) would have allowed a LEMSA to transport specified patients to a community care facility, as defined, in lieu of transportation to an acute care hospital.
• AB 1650 (Maienschein, 2017) would have created a community paramedicine program within EMSA and allowed EMSA to authorize local EMS agencies to participate in the community paramedicine program to provide services utilizing EMT-P personnel for the delivery of medical care, as specified. AB 1650 was held on the Assembly Appropriations Committee suspense file.

Staff Comments:

• Current paramedic license fees for a two year license period are:
• Initial in-state paramedic license application $250
• Initial out-of-state paramedic license application $300
• Paramedic license renewal application $200

Current licensure fees are insufficient to cover licensure and enforcement expenses and sustain the EMS Personnel Fund. EMSA is currently analyzing fee increases. A $15.00 licensure fee increase would be necessary to cover the costs associated with the additional staff and workload from the bill costs. However since applying an increase in fees to all paramedics is not appropriate due to the number of community paramedics compared to the current paramedic population, funds would need to come from the General Fund.

The EMSA notes the following resources would be required to implement the bill:

• One (1) FTE health program specialist I (HPSI) position of $147,000 in 2018-19, and $140,000 in 2019-20 and annually thereafter. The HPSI would assist with the stakeholder meetings and rulemaking process, draft protocols, monitor, receive and analyze data from the community paramedic programs and prepare reports to the legislature and post the information on EMSA’s website.
• One (1) FTE associate government program analyst (AGPA) $143,000 (2018-19) and $136,000 thereafter. This position would be necessary to facilitate the working group to draft regulations, complete the rulemaking process, review local EMS agency plans related to community paramedicine programs, and assist the health program specialist I with the collection and reporting of data as mandated by the provisions of this bill.
• $100,000 for one-year of contract services for a project manager to transition from the pilot sites.

Existing staff cannot absorb this additional workload. This fiscal estimate assumes 15 community paramedicine programs, but should that number grow, the cost would increase.

In addition, the departments notes that it will be at least three years from when the bill would be enacted for the first report. This allows for two years to complete the rulemaking process plus one year for the community paramedicine programs to collect and submit data to EMSA. EMSA would be responsible for collecting data and publishing annual reports for six years.

Key Findings from the Pilot.

• 1. Post-discharge, short-term follow-up. There were five post-discharge project sites up and running during the review period, 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. Frequent EMS users. 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 emergency department 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.
  3. Directly observed therapy for tuberculosis. The only project site in this category is in Ventura County, which asked the county’s EMS provider to collaborate with the tuberculosis clinic, because the clinic does not have sufficient staff to provide directly observed therapy to all tuberculosis patients in the county. Because Ventura is a large geographic area, it is not feasible for some patients to travel to the clinic for directly observed therapy. This project enrolled 42 patients through September 30, 2017. Because the management of tuberculosis often spans six to nine months, the community paramedics caseload averaged seven patients per month. The Institute found that community paramedics were unable to dispense only two treatments (0.06%), while community health workers were unable to dispense 6.7% of prescribed treatments. The Institute stated that this difference is due primarily to the availability of community paramedics on nights and weekends.
  4. Hospice. The goal of hospice care is to provide medical, psychological, and spiritual support to persons dying from a terminal illness in a patient’s home, a residential care facility, a nursing home, or an inpatient hospice facility. The only hospice project, in Ventura County, seeks to prevent transports that are not consistent with hospice patients’ wishes. Under this project, if a 911 dispatcher or first responder on scene determines that a person is under the care of a hospice agency participating in the pilot project, the dispatcher or first responder requests that a community paramedic come to the patient’s home. Once on scene, the community paramedic assesses the patient, talks with family members and caregivers, and contacts a registered nurse employed by the hospice agency, who directs the community paramedic regarding what care to provide. No hospice patient who requests transport to an emergency department is denied transport. 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.

• 1. Alternate destination – mental health. There was only one pilot project in this category during the review period, in Stanislaus County. Under this project, the community paramedic provides medical clearance for patients with mental health needs, and if cleared, arranges for them to be transported directly to a county-operated mental health crisis center. Community paramedics are dispatched in response to 911 calls that a dispatcher believes involve a mental health problem, or when another paramedic or a law enforcement officer identifies a patient as having mental health needs. Once on scene, the community paramedic assesses the patient to determine whether he or she has any medical needs, or is intoxicated due to alcohol or drug consumption. In addition, mental health crisis center staff have asked community paramedics to provide medical screening to “walk in” clients. This project enrolled 251 people during the review period. According to the Institute, this project potentially avoided an estimated $266,200 ($1,061 per patient) in costs because transporting a mental health patient to the crisis center avoids an emergency department visit and a secondary transport to an inpatient mental health facility, with most savings accruing to Medi-Cal.
  2. Alternate destination – sobering center. San Francisco opened a sobering center in 2003, which has now served more than 50,000 people. The sobering center is open 24 hours a day, seven days a week, and staffed by registered nurses. There are also social workers on its staff to help patients obtain other services. Most patients stay for four to 12 hours. Under this pilot project (which is new as of February of 2017), all paramedics on 911 response crews, not just the community paramedics who have completed the core curriculum, are trained to screen intoxicated patients to determine if they are eligible for the pilot project. Patients are deemed eligible if they have acute alcohol intoxication but do not have any medical or mental health needs. The project enrolled 400 patients during its first eight months of operations, and 50 of these patients have visited the sobering center more than once. The most common risk to sobering center patients is an unforeseen need for medical detoxification. Among the 400 patients enrolled in the project, nine patients were transferred to an emergency department within six hours of admission to the sobering center. These transfers were due to agitation with chest pain, alcohol withdrawal, confusion, rapid shallow breathing, a fall, a suspected suicide attempt, and a client request for oxygen. According to the Institute, eight of the nine transfers could not have been avoided because the need for transfer was not evident when the paramedics assessed the patient in the field. In the case of the patient with rapid shallow breathing (tachypnea), the conclusion was that the patient’s respiration rate in the field was outside the range for admission to the sobering center, and the 911 response crew and supervisor was coached on how to use a respiration rate in the field to determine eligibility for the sobering center. One additional patient was rerouted from the sobering center to the emergency department due to hypothermia and bradycardia. According to the Institute, during the first eight months of operation, this project generated $132,699 in potential savings ($332 per per person) due to the reduction in emergency department visits. The Institute also suggested that one of the strengths of this project was that treating these patients in a sobering center has the benefit of social workers having greater ability to connect patients with medical detoxification, social work, case management services, and permanent housing.

-- END --

SENATE JUDICIARY COMMITTEE

Senator Hannah-Beth Jackson, Chair

2017-2018 Regular Session

Bill No: SB 944 (Author:Hertzberg)

Version: March 21, 2018

Hearing Date: April 24, 2018

Fiscal: Yes

Urgency: No

Consultant: CK

SUBJECT

Community Paramedicine Act of 2018

DESCRIPTION

This bill would enact the Community Paramedicine Act of 2018. This bill would authorize local EMS agencies to develop a community paramedicine program that is consistent with regulations that would be developed by the Emergency Medical Services Authority, in consultation with the Community Paramedicine Medical Oversight Committee, which would be formed by this bill.^[1]

BACKGROUND

The Office of Statewide Health Planning and Development (OSHPD) operates the Health Workforce Pilot Projects program that supports healthcare delivery projects. It provides the legal framework for healthcare organizations to demonstrate, test, and evaluate new or expanded roles for healthcare professionals.

In 2014, the OHSPD approved a pilot project sponsored by the Emergency Medical Services Authority (EMSA). The project, Health Workforce Pilot Project #173 (the Pilot), was initially authorized to test, demonstrate, and evaluate the practice of “Community Paramedicine” in the following areas:

• transporting patients with specified conditions to alternate locations other than an acute care emergency department;
• addressing the needs of frequent 9-1-1 callers or frequent visitors to emergency departments;
• providing short-term home follow-up care for persons recently discharged from a hospital and at increased risk of a return visit to the emergency department or readmission to the hospital; and
• providing short-term home support for persons with diabetes, asthma, congestive heart failure, or multiple chronic conditions.

EMSA’s objectives in the Pilot were to demonstrate cost-effectiveness of care provided by community paramedics compared to the existing provision of care and to demonstrate that community paramedics can safely and effectively provide care that improves health care efficacy, patient-centered care, and integration of health system resources with reductions in both unnecessary ambulance transports to emergency departments and hospital readmissions.

The Pilot has operated at 13 sites testing a variety of concepts. It has been renewed several times and, unless renewed again, is scheduled to expire in November 2018.

This bill would authorize local EMS agencies to develop a community paramedicine program that is consistent with regulations that would be developed by the Emergency Medical Services Authority, in consultation with the Community Paramedicine Medical Oversight Committee, which would be formed by this bill. The regulations would be based upon, and informed by, the formation and implementation of the Pilot.

This bill passed out of the Senate Health Committee on a vote of 8 to 0.

CHANGES TO EXISTING LAW

Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, states its intent is to provide the state with a statewide system for emergency medical services. (Health & Saf. Code Sec. 1797 et seq.)

Existing law establishes the Emergency Medical Services Authority (EMSA) and charges it with developing planning and implementation guidelines for emergency medical services systems addressing specified components. (Health & Saf. Code Sec. 1797.100 et seq.)

Existing law authorizes each county to develop an emergency medical services program. Such counties are required to designate a local EMS agency which shall be the county health department, an agency established and operated by the county, an entity with which the county contracts for the purposes of local emergency medical services administration, or a joint powers agency created for the administration of emergency medical services by agreement between counties or cities and counties as specified. (Health & Saf. Code Sec. 1797.200.)

Existing law establishes the Commission on Emergency Medical Services in the Health and Human Services Agency. The commission must review and approve regulations, standards, and guidelines to be developed by EMSA for implementation of the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act. (Health & Saf. Code Sec. 1799 et seq.)

Existing law authorizes the Office of Statewide Health Planning and Development to designate experimental health workforce projects as approved projects where the projects are sponsored by community hospitals or clinics, nonprofit educational institutions, or government agencies engaged in health or education activities. Nothing in this section shall preclude approved projects from utilizing the offices of physicians, dentists, pharmacists, and other clinical settings as training sites. (Health & Saf. Code Sec. 128135.)

Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, provides a series of limitations on liability. (Health & Saf. Code Sec. 1799.100 et seq.)

This bill would enact the Community Paramedicine Act of 2018 with the intent to establish state guidelines that govern the implementation of community paramedicine programs by local EMS agencies in California.

This bill would create the Community Paramedicine Oversight Committee. EMSA would be required to develop, in consultation with the committee, regulations that establish minimum standards for the development of a community paramedicine program. The Commission on Emergency Medical Services would be required to review and approve such regulations before adoption.

This bill would require EMSA to develop and adopt, with approval from the committee, minimum medical protocols for each community paramedicine program specialty authorized by the bill.

This bill would define “community paramedicine program” as a program developed by a local EMS agency and approved by the Emergency Medical Services Authority to provide community paramedic services consisting of one or more specified program specialties, under the direction of medical protocols developed by the local EMS agency that are consistent with the minimum medical protocols established by the authority. Community paramedic services would consist of the following program specialties:

• providing short-term postdischarge followup for persons recently discharged from a hospital due to a serious health condition;
• providing directly observed therapy to persons with tuberculosis;
• providing case management services to frequent emergency medical services users;
• providing hospice services to treat hospice patients in their homes, in collaboration with the patient’s hospice agency, in response to 911 calls; and
• providing patients with transport to an alternate destination facility.

This bill would authorize local EMS agencies to develop community paramedicine programs consistent with EMSA’s regulations. EMSA would be required to submit annual reports on the programs operating in California to the relevant policy committees of the Legislature.

This bill would prohibit a person or organization from providing community paramedic services or representing, advertising, or otherwise implying that it is authorized to provide community paramedic services unless it is expressly authorized by a local EMS agency to provide those services as part of a community paramedicine program approved by EMSA. A community paramedic would only be authorized to provide community paramedic services if the community paramedic has been certified to perform those services by a local EMS agency and is working as an employee of an authorized community paramedicine provider.

This bill provides that the disciplinary procedures for a community paramedic shall be consistent with subdivision (d) of Section 1797.194.

This bill would apply the liability provisions described in Chapter 9 (commencing with Section 1799.100) of the Health and Safety Code to the bill.

COMMENT

1. Stated need for the bill

According to the author:

The Office of Statewide Health Planning and Development Health Workforce Pilot Project #173 is set to expire at the end of 2018. Without authorizing legislation, these pilot programs in various jurisdictions would be forced to shut down. They have demonstrated success and merit moving forward. We have learned a great deal from the pilot programs. As a result, SB 944 builds in needed improvements and structure to community paramedicine programs in the post-pilot program environment. The pilot programs have demonstrated improved care strategies to better connect patients with needed services like mental health crisis centers and sobering centers. These programs can play a role in improved patient services that could result in reductions in emergency room overcrowding while improving patient care.

2. Policy implications of providing immunity

As a general rule, California law provides that persons are responsible, not only for the result of their willful acts, but also for an injury occasioned to another by their want of ordinary care or skill in the management of their property or person, except so far as the latter has, willfully or by want of ordinary care, brought the injury upon themselves. (Civ. Code Sec. 1714(a).) Although immunity provisions are rarely preferable, the Legislature has in limited scenarios approved measured immunity from liability (as opposed to blanket immunities) to promote other policy goals that could benefit the public.

As a matter of policy, the Legislature has generally been reluctant to further immunize the acts of public employees and public agencies except in narrow circumstances. Immunity from liability disincentivizes careful planning and acting on the part of governmental actors. When an agency enjoys immunity from civil liability, it is relieved of the responsibility to act with due regard and an appropriate level of care in the conduct of its activities. Immunity provisions are also disfavored because they, by their nature, preclude parties from recovering when they are injured, and force injured parties to absorb losses for which they are not responsible. Liability acts not only to allow a victim to be made whole, but to encourage appropriate compliance with legal requirements.

Immunities are generally afforded when needed to incentivize certain conduct, such as the provision of life-saving or other critical services. Examples include protections for use of CPR, Civil Code Section 1714.2; use of an automated external defibrillator, Civil Code Section 1714.21; and use of opiate overdose treatment, Civil Code Section 1714.22. However, as indicated above, rarely is immunity absolute, and these immunities generally do not cover grossly negligent conduct or intentional misconduct.

3. Applying the liability limitations of the Emergency Medical Services System and the

Prehospital Emergency Medical Care Personnel Act

The Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act (the Act) was enacted to provide the state with a statewide system for emergency medical services by establishing within the Health and Welfare Agency the Emergency Medical Services Authority, which is responsible for the coordination and integration of all state activities concerning emergency medical services. (Health & Saf. Code Sec. 1797 et seq.) One chapter of the act includes a series of liability provisions. (Health & Saf. Code Sec. 1799.100 et seq.)

One provision provides immunity from any civil damages for public and private entities that voluntarily and without expecting compensation donate services, goods, labor, equipment, resources, or dispensaries or other facilities, or which sponsor, authorize, support, finance, or supervise the training of people, or certifies them, in emergency medical services. (Health & Saf. Code Sec. 1799.100.) The stated goal of this immunity is to encourage local agencies and other organizations to train people in emergency medical services. Another section provides that no person who in good faith, and not for compensation, renders emergency medical or nonmedical care at the scene of an emergency shall be liable for any civil damages resulting from any act or omission. (Health & Saf. Code Sec. 1799.102.) The scene of an emergency does not include emergency departments and other places where medical care is usually offered. This provision only applies to specified medical, law enforcement, and emergency personnel; a companion provision creates a qualified immunity for other individuals.

The Act also provides immunity from liability for civil damages to a physician or nurse, who in good faith gives emergency instructions to an EMT-II or mobile intensive care paramedic at the scene of an emergency. (Health & Saf. Code Sec. 1799.104.) An EMT-II or mobile intensive care paramedic rendering care within the scope of their duties who, in good faith and in a nonnegligent manner, follows those instructions cannot be held liable for any civil damages as a result of following such instructions.

Pursuant to the act, a firefighter, police officer or other law enforcement officer, EMT-I, EMT-II, EMT-P, or registered nurse who renders emergency medical services at the scene of an emergency or during an emergency air or ground ambulance transport is only liable in civil damages for grossly negligent or bad faith conduct. (Health & Saf. Code, § 1799.106.) It only holds their public agency employers liable if these personnel are liable. Also immune from liability, unless the conduct was grossly negligent or in bad faith, are public entities and emergency rescue personnel acting within the scope of their employment in their provision of emergency services and any properly certified person providing prehospital emergency field care treatment at the scene of an emergency. (Health & Saf. Code Secs. 1799.107, 1799.108.)

The Act’s liability limitations provide definitions for “registered nurse,” “emergency rescue personnel,” “emergency medical services,” “emergency medical care,” “scene of an emergency,” and “emergency services.”

These immunity provisions are narrowly tailored to specific situations and specific personnel. From a policy standpoint, civil immunity is extended to individuals in these emergency situations because it reflects a policy recognition that a person cannot be expected to act as reasonably or clear thinking when faced with danger or an emergency situation as they normally would.

This bill would provide that these liability limitations would apply to the bill’s provisions. Such a provision is likely unnecessary but ensures that these liability limitations apply where the criteria of any particular limitation within the Act is met. The provision regarding liability in this bill does not expand the scope or application of these liability provisions.

4. Amendments agreed to in the Senate Health Committee

The following amendments were agreed to by the author in the Senate Health Committee:

Amend Section 1797.272 (b) to read: “(b) If a local EMS agency within the county elects to develop a community paramedicine program pursuant to Section 1840, the county board of supervisors shall establish an emergency medical care committee and shall also include the following members to advise the local EMS agency on the development of the community paramedicine program:”

Amend Section 1815(d) to read: “(d) Providing services to treat hospice patients in their homes, in collaboration with the patient’s hospice agency, in response to 911 calls.”

Amend Section 1830(a) to read: “(a) The Community Paramedicine Medical Oversight Committee is hereby created within the Emergency Medical Services Authority to advise the authority on, and approve minimum medical protocols for, the community paramedicine program specialties described in Section 1815.”

Amend Section 1830(b)(3) to read: “(3) Two emergency medical technician paramedics (EMT-Ps), one EMT-P employed by a public agency from a list of three names provided by the California Professional Firefighters and one EMT-P employed by a private ambulance company from a list of three names provided by the California Labor Federation.”

Amend Section 1830(b)(6) to read: “(6) One inpatient hospitalist who is a physician whose primary professional focus is the general medical care of hospitalized patients from a list of three names submitted by the California Hospital Association.”

Amend Section 1831(a) to read: “1831. (a) The Emergency Medical Services Authority shall develop, in consultation with the Community Paramedicine Medical Oversight Committee, regulations that establish minimum standards for the development of a community paramedicine program.”

Amend Section 1832(a) to read: “(a) The Emergency Medical Services Authority shall develop and, after approval by the Community Paramedicine Medical Oversight Committee, adopt minimum medical protocols for each community paramedicine program specialty described in Section 1815.”

Amend Section 1841(d) to read: “(d) If the community paramedicine program provides the program specialties described in subdivisions (a) to (c), inclusive, of Section 1815, the local EMS agency shall enter into an agreement for the provision of those specialties according to the following:”

Amend Section 1841(e) to read: “(e) If the community paramedicine program provides the program specialties described in subdivision (d) and (e) of Section 1815, the local EMS agency shall do all of the following:”

Insert the following Section: “1855. This chapter shall remain in effect only until January 1, 2025, and as of that date is repealed, unless a later enacted statute, that is enacted before January 1, 2025, deletes or extends that date.”

Insert a sunset provision in Section 1797.272(c) for January 1, 2025 and a section that would restore existing Section 1797.72 as of that sunset date.

Support: County of Santa Clara

Opposition: California Association for Health Services at Home; California Nurses Association/National Nurses United

HISTORY

Source: California Professional Firefighters

Related Pending Legislation: AB 1795 (Gipson, 2018) would authorize local emergency medical services agencies to include, as part of its emergency medical services plan, a program to transport specified patients who meet triage criteria to a behavioral health facility or a sobering center, as defined. It would require EMSA to develop and adopt guidelines for such programs. This bill is currently in the Assembly Appropriations Committee.

Prior Legislation:

AB 820 (Gipson, 2017) would have authorized a local emergency medical services agency to transport specified patients to a community care facility, as defined, in lieu of transportation to a general acute care hospital. This bill died in the Assembly Health Committee.

AB 1650 (Maienschein, 2017) would have created the Community Paramedic Program within EMSA and allowed EMSA to authorize local emergency medical services agencies to participate in the program. This bill died in the Assembly Appropriations Committee.

Prior Vote: Senate Health Committee (Ayes 8, Noes 0)

**************

1. This analysis includes amendments agreed to by the author in the Senate Health Committee. This analysis is of the bill as so amended. ↑

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 944

SUBJECT: Community Paramedicine Act of 2018

SUMMARY:

Enacts the Community Paramedicine Act of 2018, which permits local emergency medical services agencies, with approval by the Emergency Medical Services Authority, develop a program to provide community paramedic services in or more of the following five 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.

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. Authorizes counties to develop an EMS program and designate a local EMS agency responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations. [HSC §1797.200 et seq.]
3. Requires the administration of prehospital EMS by cities and fire districts providing such services as of June 1, 1980, to be retained by those cities and fire districts and to be continued at not less than the existing level until such time that a written agreement is reached between a city or fire district and a county. [HSC §1797.201]
4. Permits a local EMS agency to create one or more exclusive operating areas in the development of a local plan, if a competitive process is utilized to select the provider or providers of the services. Specifies that no competitive process is required if the local EMS agency develops or implements a local plan that continues the use of existing providers operating within a local EMS area in the manner and scope in which the services have been provided without interruption since January 1, 1981. [HSC §1797.224]
5. 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 review and report to the local EMS agency and EMSA regarding the operations of ambulance services, emergency medical care, and first aid practices in the county. [HSC §1797.270 et seq.]
6. 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 emergency facilities and services, emergency communications, medical equipment, personnel training, and various aspects of the EMS system; and, to make recommendations for further development of the EMS system. [HSC §1799 et seq.]
7. Requires the Commission on EMS to review and approve regulations, standards and guidelines to be developed by EMSA for implementation of the EMS system and the Prehospital Emergency Medical Care Personnel Act. [HSC §1799.50]
8. 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]
9. 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.]
10. Permits OSHPD to designate HWPPs as approved projects where the projects are sponsored by community hospitals or clinics, nonprofit educational institutions, or governmental agencies engaged in health or education activities. Permits a trainee (defined as a person being taught health care skills) in an approved project to perform health care services under the supervision of a supervisor (someone who is already licensed to provide the health care services) where the general scope of the services has been approved by OSHPD. [HSC §128135 and §128140]
11. Requires hospital emergency departments, under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and also under similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State EMTALA imposes this requirement on any hospital that operates an emergency department. [HSC §1317 et seq.]

This bill:

1. Establishes the Community Paramedicine Act of 2018, and states the intent of the Legislature that, among other things, an alternative destination facility participating as part of an approved community paramedicine program will always be staffed by a higher medical authority, that the delivery of community paramedic services is a public good and is complementary to the existing emergency response system, and that whenever possible, public agencies that provide first response services should delivery care under a community paramedicine program.
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 paramedic 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 postdischarge followup for persons recently discharged from a hospital due to a serious health condition;
   2. Providing directly observed therapy to persons with tuberculosis;
   3. Providing case management services to frequent EMS users;
   4. Providing hospice services to treat patients in their homes; and,
   5. Providing patients with transport to an alternate destination facility.
3. 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 facility that is a licensed psychiatric hospital, a licensed psychiatric health facility, or a certified crisis stabilization unit, and has at least one registered nurse staffed onsite at the facility at all times;
   3. “Authorized sobering center” is a facility that is a federally qualified health center or a federally qualified county clinic and has at least one registered nurse staffed onsite at the facility at all times;
   4. “Community paramedic” is a licensed paramedic who has completed the core curriculum for community paramedicine as described in this bill, has received certification in one or more of the community paramedicine program specialities 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; and,
   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.
4. Establishes the Community Paramedicine Oversight Committee (Oversight Committee) within EMSA to advise the EMSA on, and approve minimum medical protocols for, the community paramedicine program specialties specified in 2) above. Requires the Oversight Committee to consist of 11 members, all appointed by the Governor, as follows:
   1. Two full-time physicians whose primary practice is emergency medicine, appointed from a list of five names submitted by the California Chapter of the American College of Emergency Physicians;
   2. Two registered nurses from a list of five names provided by the California Labor Federation;
   3. Two emergency medical technician paramedics from a list of five names provided by the California Professional Firefighters and the California Labor Federation;
   4. Two medical directors of local EMS agencies from a list of five names submitted by the EMS Medical Directors Association of California;
   5. One local EMS agency administrator from a list of three names submitted by the EMS Administrators Association of California;
   6. One inpatient hospitalist from a list of three names submitted by the California Hospital Association; and,
   7. One mental health professional from a list of three names provided by the California Psychiatric Association.
5. Requires EMSA to develop, in consultation with the Oversight Committee, regulations that establish minimum standards for the development of a community paramedicine program, and requires the Commission on EMS to review and approve the regulations before EMSA adopts them.
6. Requires the regulations developed pursuant to 5) above to be based upon, and informed by, the formation and implementation of the Community Paramedicine Pilot Program under HWPP #173 (HWPP #173), and to consist of all of the following:
   1. Minimum standards and core curriculum for community paramedic training;
   2. Minimum standards for the scope of practice for each community paramedicine program specialty described in 2) above;
   3. A process for certifying a community paramedic who completes the core curriculum training;
   4. Minimum standards for approval, review, withdrawal, and revocation of a community paramedicine program; and,
   5. Minimum standards for collecting and submitting data to the authority to ensure patient safety that include consideration of both quality assurance and quality improvement.
7. Requires the minimum standards in 6) e) above to include all of the following:
   1. Intervals for community paramedicine providers, participating health facilities, and local EMS agencies to submit community paramedicine data;
   2. Relevant program use data;
   3. Public posting of program analysis;
   4. Emergency medical response system feedback, including feedback from the emergency medical care committee, as specified;
   5. If the community paramedicine program utilizes an alternate destination facility, consideration of ambulance patient offload times for both the alternate destination facility and existing emergency departments, the number of patients that are turned away, diverted, or required to be subsequently transferred to an emergency department, and identification of the reasons for turning away, diverting, or transferring the patient;
   6. An assessment of each community paramedicine program’s medical protocols or other processes; and,
   7. An assessment of the impact that implementation of a community paramedicine program has on the delivery of EMS and response times in the local EMS agency’s jurisdiction.
8. Requires EMSA to develop, and after approval by the Oversight Committee, establish minimum medical protocols for each community paramedicine program specialty described in 2) above. Requires these protocols to be based upon, and informed by, the formation and implementation of HWPP #173, and further refinements provided by local EMS agencies during the course and operation of HWPP #173.
9. Requires EMSA to submit an annual report on the community paramedicine programs operating in California to the relevant policy committees of the Legislature. Requires EMSA to submit its first report six months after EMSA adopts the regulations specified in 5) above, and every January 1 thereafter for the next five years. Permits this report to include recommendations for authorizing additional community paramedicine program specialties, or recommendations for changes to, or the elimination of, the community paramedicine program specialties that do not achieve the community health and patient goals of this bill. Repeals these reporting provisions six years after the authority adopts the regulations specified in 5) above.
10. Permits a local EMS agency to develop a community paramedicine program that is consistent with EMSAs regulations and the provisions of this bill and submit it to EMSA for approval. Requires EMSA to review a local EMS agency’s proposed community paramedicine program to ensure it is consistent with EMSAs regulations and the provisions of this bill.
11. Requires EMSA to approve, approve with conditions, or deny the proposed community paramedicine 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 the provisions of this bill.
12. Permits a community paramedicine pilot program approved under HWPP #173 before January 1, 2019, to continue operations until six months after the regulations described in 5) above become effective.
13. Requires a local EMS agency that opts to develop a community paramedicine program to do all of the following:
    1. Integrate the proposed community paramedicine program into the local EMS agency’s EMS plan, as defined;
    2. Develop a process, consistent with this bill, to select community paramedicine providers at a periodic interval of no more than ten years; and,
    3. Enter into an agreement with a community paramedicine provider for the delivery of community paramedic services within the local EMS agency’s jurisdiction that are consistent with the proposed community paramedicine program. 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.
14. Requires the local EMS agency, if the community paramedicine program provides the program specialties described in 2) above (except for alternate destination), to enter into an agreement for the provision of those specialties according to the following:
    1. Requires a local EMS agency to solicit every public agency that is located within its jurisdiction to provide the proposed community program specialties, and if a public agency agrees to provide all of those specialties, requires the local EMS agency to enter into a written agreement with the public agency to provide those specialties;
    2. Permits the local EMS agency, if a public agency agrees to provide only some of the specialties, to establish a competitive bid process to select a community paramedicine provider to deliver the specialties not provided by the public agency; and,
    3. Requires the local EMS agency, if no public agency chooses to provide the proposed community program specialties, to establish a competitive bid process to select a community paramedicine provider to deliver the specialties.
15. Requires a local EMS agency, if the community paramedicine program provides the specialty of transport to an alternate destination facility, to do all of the following:
    1. Enter into an agreement that continues the use of existing providers operating within the local EMS agency’s jurisdiction in the manner and scope in which that service has been provided by the existing provider, as specified;
    2. Certify 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;
    3. Collaborate with the emergency medical care committee to develop medical protocols that describe when the use of an alternate destination facility is in the best interests of the patient and, upon approval of the medical director of the local EMS agency, submit the protocols to EMSA. Requires the medical protocols to be consistent with the requirements of EMSA’s regulations, and permits the protocols to include provisions describing the qualified staff to care for the degree and severity of a patient’s injuries and needs, the equipment and services available at an alternative destination facility necessary to care for patients, and time of day and any limitations that may apply for an alternate destination facility;
    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 community paramedicine program.
16. Requires a local EMS agency that opts to develop a community paramedicine program to:
    1. Establish a process for training and certification of community paramedics in the proposed community paramedicine program’s specialties; and,
    2. To facilitate and participate in any agreements between a community paramedicine provider and public or private health system participants to provide funding to support implementation of the local EMS agency’s community paramedicine program.
17. Requires, if a local EMS agency opts to develop a community paramedicine program, the EMCC to also include the following members and to advise the local EMS agency on the development of the community paramedicine program:
    1. Two emergency room physicians practicing at an emergency department within the local EMS agency’s jurisdiction;
    2. Two registered nurses practicing within the local EMS agencies jurisdiction;
    3. Two EMT-Ps practicing in the local EMS agency’s jurisdiction, at least one of whom must be employed by a public agency.
    4. The medical director for the local EMS agency; and,
    5. One acute care hospital representative with an emergency department operating within the local EMS agency jurisdiction.
18. Prohibits a person or organization from providing community paramedic services unless it is expressly authorized by a local EMS agency to provide those services as part of a community paramedicine program approved by EMSA.
19. 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.
20. Requires the disciplinary procedures for a community paramedic to be consistent with specified provisions of existing law related to EMT-Ps.
21. Prohibits entering into an agreement to be a community paramedicine provider under this bill from altering or otherwise invalidating a public agency’s authority to provider or administer emergency medical services under specified provisions of existing law related to exclusive operating areas and the continuation of local city and fire district contracts to provide emergency services.
22. 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.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, community paramedicine is a concept that aims to improve the efficiency and delivery of health care using trained paramedics and other health care providers to address local needs. In November of 2014, OSHPD approved an application by EMSA for the operation of specific paramedicine programs in various local EMS agencies in the state. Fourteen projects were approved throughout the state, including projects in San Diego and Ventura County, which enrolled 2,515 patients from June 2015 through September 2017. The paramedicine programs had many positive results on the communities they served – the post-discharge projects reduced the 30-day readmission rate for individuals with one or more chronic conditions targeted and they saved potential costs of $1.4 million. Additionally, patients under the observed tuberculosis (TB) therapy programs were more likely to receive all their doses of TB medication than patients who were not. Authorizing these community paramedicine concepts, with appropriate state and local oversight and input, will allow these innovative projects to continue to make the delivery of healthcare services more efficient while maintaining the highest level of patient care.
2. Paramedic training and scope of practice. Under regulations adopted by EMSA, paramedic training consists of a minimum of 1090 hours. These training hours are divided into: 450 hours of didactic instruction and skills laboratories; 160 hours of hospital clinical training; and, a field internship of 480 hours. During the field internship, the paramedic student is required to have a minimum of 40 advanced life support patient contacts, which is defined as the student performance of one or more of advanced life support skills. Following the training program, paramedic applicants are required to pass both a written and practical examination. In addition to state licensure by EMSA, paramedics are required to have “local accreditation” by a local EMS agency in order to practice as a paramedic within that jurisdiction. Under their scope of practice, a paramedic is authorized to perform specified advanced life support procedures and administer specified medications while at the scene of a medical emergency or during transport or during interfacility transfer, or while working in a small and rural hospital, as specified. Procedures that paramedics are authorized to perform include utilizing and monitoring electrocardiograms, defibrillation, adult endotracheal intubation, instituting intravenous catheters or other IV lines in peripheral veins, and monitoring and administering medications through pre-existing vascular access. Regulations specify a list of 25 medications that a paramedic is authorized to administer.
3. Background on HWPP #173. In November of 2014, OSHPD approved an application from EMSA to establish HWPP #173, to test different concepts of community paramedicine. Initially, HWPP #173 encompassed 13 sites testing the following six concepts:
4. Post-Discharge Short-Term Follow-Up, intended to provide home-based follow up care to people recently discharged from a hospital due to a chronic condition;
5. Frequent EMS Users, intended to provide case management to frequent 911 callers and frequent visitors to emergency departments by connecting them with primary care, behavioral health, housing, and social services;
6. Directly Observed Therapy for Tuberculosis, where the paramedic dispensed medication and observed patients taking them to assure effective treatment;
7. Hospice, where paramedics, in response to 911 calls, collaborated with hospice agency nurses, patients, and family members to treat patients in their homes, according to their wishes, instead of transporting to an emergency department;
8. Alternate Destination – Behavioral Health, where paramedics, in response to 911 calls, offer to transport people who have behavioral health needs but no emergency medical needs to a mental health crisis center instead of an emergency department; and,
9. Alternate Destination – Urgent Care, where paramedics, responding to 911 calls, offer people with low-acuity medical conditions transport to an urgent care center instead of an emergency department.

A seventh concept began enrolling patients in February of 2017: San Francisco’s Alternate Destination – Sobering Center, where paramedics, in response to 911 calls, offer people who are acutely intoxicated but do not have acute medical or mental health needs transport directly to a sobering center for monitoring instead of an emergency department. Since its initial approval for a one-year period, HWPP #173 has been renewed three times. The last renewal was in November of 2017, and unless renewed again, it is scheduled to end on November 14, 2018. Nine new project sites were approved to begin enrolling patients this year, while four project sites have closed, including all three Alternate Destination – Urgent Care project sites, which were closed due to low enrollment.

Paramedics who wished to participate in HWPP #173 were required to have had at least four years of experience, be volunteers, and be sponsored by their local EMS agency. A core curriculum was developed that OSHPD reviewed and approved, which was adapted from the Paramedic Foundation’s National Community Paramedic Curriculum. The curriculum specified 48 hours of didactic, classroom-based instruction, and 48 hours of clinical, hands-on training. Additionally, community paramedic trainees were required to complete 56 hours of study outside of the classroom. There were 77 paramedics who completed the core curriculum and made up the initial cohort of community paramedics, although others have since completed the training. Collectively, HWPP #173 enrolled 2,515 patients from June 2015 through September 2017 across all project sites (the most recent data available). The post-discharge projects enrolled the largest number of patients and the tuberculosis project had the smallest.

1. Report on the six HWPP #173 concepts incorporated into this bill. Pursuant to the requirement in law that the sponsor of HWPPs retain an independent evaluator to assess trainee performance, patient acceptance, and cost-effectiveness, the Phillip R. Lee Institute for Health Policy Studies and the Healthforce Center (formerly the Center for Health Professions) at the University of California, San Francisco (Institute) issued an initial report in January 2017, and updated twice since, with the most recent evaluation published on February 7, 2018. Below is a summary of the report on each concept affected by this bill (Alternative Destination – Urgent Care is not included below, because all project sites testing this concept have closed, and it is not part of this bill).
   1. Post-discharge, short-term follow-up. There were five post-discharge project sites up and running during the review period, 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. Frequent EMS users. 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 emergency department 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.
   3. Directly observed therapy for tuberculosis. The only project site in this category is in Ventura County, which asked the county’s EMS provider to collaborate with the tuberculosis clinic, because the clinic does not have sufficient staff to provide directly observed therapy to all tuberculosis patients in the county. Because Ventura is a large geographic area, it is not feasible for some patients to travel to the clinic for directly observed therapy. This project enrolled 42 patients through September 30, 2017. Because the management of tuberculosis often spans six to nine months, the community paramedics caseload averaged seven patients per month. For this project, clinic leaders assigned patients to community paramedics who resist treatment or who were verbally abusive or sexually inappropriate because paramedics have more experience and training that the community health workers in managing persons with challenging behavior. They were also more likely to be assigned homeless persons and other patients who are difficult to locate. According to the Institute, patients who received directly observed therapy from community paramedics were more likely to receive all doses of medication prescribed by the clinic physician than people who received directly observed therapy from the clinic’s community health workers. The Institute found that community paramedics were unable to dispense only two treatments (0.06%), while community health workers were unable to dispense 6.7% of prescribed treatments. The Institute stated that this difference is due primarily to the availability of community paramedics on nights and weekends.
   4. Hospice. The goal of hospice care is to provide medical, psychological, and spiritual support to persons dying from a terminal illness 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 other 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, but despite this instruction, some hospice patients and their families call 911 instead of the hospice. The standard response to a 911 call made on behalf of a hospice patient is to transport the patient to an emergency department, which may be upsetting for hospice patients, and may lead to medical interventions that the hospice patient would prefer not to receive. The only hospice project, in Ventura County, seeks to prevent transports that are not consistent with hospice patients’ wishes. Under this project, if a 911 dispatcher or first responder on scene determines that a person is under the care of a hospice agency participating in the pilot project, the dispatcher or first responder requests that a community paramedic come to the patient’s home. Once on scene, the community paramedic assesses the patient, talks with family members and caregivers, and contacts a registered nurse employed by the hospice agency, who directs the community paramedic regarding what care to provide. No hospice patient who requests transport to an emergency department 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.

• 1. Alternate destination – mental health. There was only one pilot project in this category during the review period, in Stanislaus County. Under this project, the community paramedic provides medical clearance for patients with mental health needs, and if cleared, arranges for them to be transported directly to a county-operated mental health crisis center. Community paramedics are dispatched in response to 911 calls that a dispatcher believes involve a mental health problem, or when another paramedic or a law enforcement officer identifies a patient as having mental health needs. Once on scene, the community paramedic assesses the patient to determine whether he or she has any medical needs, or is intoxicated due to alcohol or drug consumption. In addition, mental health crisis center staff have asked community paramedics to provide medical screening to “walk in” clients. This project enrolled 251 people during the review period. According to the Institute, the evaluation team found no evidence of patient harm caused by this project. Only nine patients enrolled in the project were transferred to an emergency department within six hours of arrival at the crisis center. Seven of these were subsequently transferred to an inpatient psychiatric facility, while the other two patients were discharged from the emergency department without transfer. Additionally, eight of the nine transfers occurred during the first six months in which the project was in operation, suggesting efforts to develop improved protocols and screening methods reduced the likelihood of a transfer. Overall, 26% of mental health patients were transported to the mental health crisis center instead of an emergency department. An additional 26% met the eligibility criteria and could have been transported to the crisis center if additional beds were available. The community paramedics determined that 389 people (40% of patients assessed) were not eligible for transport to the mental health crisis center because they had a medical need, had vital signs outside the parameters, were intoxicated, violent, agitated, or over age 65. According to the Institute, this project potentially avoided an estimated $266,200 ($1,061 per patient) in costs because transporting a mental health patient to the crisis center avoids an emergency department visit and a secondary transport to an inpatient mental health facility, with most savings accruing to Medi-Cal.
  2. Alternate destination – sobering center. San Francisco opened a sobering center in 2003, which has now served more than 50,000 people. The sobering center is open 24 hours a day, seven days a week, and staffed by registered nurses. There are also social workers on its staff to help patients obtain other services. Most patients stay for four to 12 hours. Under this pilot project (which is new as of February of 2017), all paramedics on 911 response crews, not just the community paramedics who have completed the core curriculum, are trained to screen intoxicated patients to determine if they are eligible for the pilot project. Patients are deemed eligible if they have acute alcohol intoxication but do not have any medical or mental health needs. If they meet the criteria, patients are offered the choice of transport to the sobering center or to the emergency department. Ten experienced paramedics have completed the full community paramedic training, and these community paramedics work with 911 response crews and the sobering center’s staff to perform quality assurance reviews for patients transported to the sobering center, and they provide training and are available to paramedics by telephone or in person for consultation if paramedics in the field are unsure whether a patient is eligible for transport to the sobering center. The project enrolled 400 patients during its first eight months of operations, and 50 of these patients have visited the sobering center more than once. The most common risk to sobering center patients is an unforeseen need for medical detoxification. Among the 400 patients enrolled in the project, nine patients were transferred to an emergency department within six hours of admission to the sobering center. These transfers were due to agitation with chest pain, alcohol withdrawal, confusion, rapid shallow breathing, a fall, a suspected suicide attempt, and a client request for oxygen. According to the Institute, eight of the nine transfers could not have been avoided because the need for transfer was not evident when the paramedics assessed the patient in the field. In the case of the patient with rapid shallow breathing (tachypnea), the conclusion was that the patient’s respiration rate in the field was outside the range for admission to the sobering center, and the 911 response crew and supervisor was coached on how to use a respiration rate in the field to determine eligibility for the sobering center. One additional patient was rerouted from the sobering center to the emergency department due to hypothermia and bradycardia. According to the Institute, during the first eight months of operation, this project generated $132,699 in potential savings ($332 per per person) due to the reduction in emergency department visits. The Institute also suggested that one of the strengths of this project was that treating these patients in a sobering center has the benefit of social workers having greater ability to connect patients with medical detoxification, social work, case management services, and permanent housing.

1. Double referral. This bill is double referred. Should it pass out of this committee, it will be referred to the Senate Judiciary Committee.
2. Related legislation. AB 1795 (Gipson) Authorizes a local EMS agency to submit, as part of its EMS plan, a plan to transport specified patients who meet triage criteria to a behavioral health facility or a sobering center, as defined. Authorizes a city, county, or city and county to designate, and contract with, a sobering center to receive patients, and would establish sobering center standards. Requires EMSA to adopt guidelines for the triage criteria and assessment procedures by July 1, 2020, and requires EMSA to annually analyze administration of local plans and issue a report, as specified. AB 1795 is set for hearing on April 17, 2018 in Assembly Health Committee.
3. Prior legislation. AB 820 (Gipson of 2017) would have allowed a LEMSA to transport specified patients to a community care facility, as defined, in lieu of transportation to an acute care hospital. AB 820 was held in the Assembly Health Committee.

AB 1650 (Maienschein of 2017) would have created a community paramedicine program within EMSA and allowed EMSA to authorize local EMS agencies to participate in the community paramedicine program to provide services utilizing EMT-P personnel for the delivery of medical care, as specified. AB 1650 was held on the Assembly Appropriations Committee suspense file.

1. 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 Local Health Plans of California (LHPC) writes in support that recent pilot programs have demonstrated the value of leveraging trusted community resources, like firefighters, mental health facilities and sobering centers, for improving and expanding our health care system. LHPC states that this bill would provide a reasonable, thoughtful pathway for expanding these important programs.
2. Letter of concern. The California Medical Association (CMA) submitted a letter of concern, stating that it believes the decision to divert a patient away from an emergency department is a medical diagnosis and certain safety parameters need to be in place to ensure patient safety. CMA states that this bill delegates decision making approval as to what community paramedicine projects are allowed to EMSA, and that at a minimum, this bill needs to clearly define what the proposed scope expansion for paramedics is and what additional training requirements need to be fulfilled before allowing paramedics to start diverting patients away from emergency departments. CMA also states that the existing requirement that emergency physicians not discriminate against patients based on ability to pay should also be included in this bill, and that there needs to be data collection and a sunset date so the Legislature can determine whether these projects are operating in a safe manner.
3. 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 is not the appropriate bill to authorize community paramedic services. CAA states that this bill restricts private ambulance companies from being able to provide community paramedic services. CAA states that this bill imposes new mandates on local EMS agencies and weakens local control. According to CAA, this bill advances the authority and control of fire departments and fire districts, while sacrificing coordinated EMS services for the public.
   
   The California Nurses Association/National Nurses United (CNA) states in opposition that this bill threatens patient safety by authorizing the use of fire and ambulance paramedics to provide healthcare services currently provided by physicians, registered nurses, and licensed behavioral health professionals. CNA states that under HWPP #173 paramedics are undertaking care with limited training, not nearly enough for them to acquire the level of expertise and skill needed. For example, CNA states that in that case of the sobering center pilot, alternate destination paramedics receive only eight additional hours of training. CNA argues that patient safety should be paramount, rather than cost savings. With regard to the specific projects, CNA argues that the number of enrollees in many of the projects was very low, the patient population did not reflect California’s diversity, the evaluation of the projects contained selective use of data, and that the high proportion of Medi-Cal users among enrollees indicated a tendency toward a two-tiered system of care. 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 including hospice care within a community paramedicine program, this bill is inserting non-hospice and non-hospice licensed individuals into the care of an individual who has elected hospice care and has foregone curative treatment. In addition, CHPCA states that this bill raises questions of liability and responsibility for payment within the hospice capitated system.

1. Policy comments.
   1. Public agency vs. private EMS provider. This bill makes a distinction between the alternate destination community paramedicine specialty, which is part of a 911 response, and the other forms of community paramedicine that are not part of the 911 response system. For the alternate destination specialty, this bill specifies that the local EMS agency enter into an agreement that “continues the use of existing providers” operating within the local EMS agency’s jurisdiction in the “manner and scope” in which that service has been provided by the existing provider. However, for the other types of community paramedicine specialties, including Directly Observed Therapy for Tuberculosis, Post-Discharge, Short-Term Follow-Up, and Frequent EMS Users, this bill gives priority to public EMS providers, such as fire departments, by requiring the local EMS agency to solicit every public agency located within its jurisdiction, and enter into a contract with every public agency that agrees to provide one or more of the community paramedicine specialties. Only after a public agency declines to provide one or more of the specialties is the local EMS agency required to establish a competitive bid process to select a community paramedicine provider to deliver those specialties.
      
      In the findings and declarations, this bill declares the intent of the Legislature that, “whenever possible, and in furtherance of the public interest and public good, public agencies that provide first response services should deliver care under a community paramedicine program.” However, in the various project sites under HWPP #173, both public agencies and private ambulance providers participated in the project. In particular, both the Hospice and the Directly Observed Therapy for Tuberculosis projects in Ventura County (these two were the only projects of their type in the pilot) used exclusively private ambulance companies as the paramedic provider. The Frequent EMS User project site in San Diego had public agencies as well as private ambulance company involvement. Should this bill be enacted, if a local EMS agency wanted to continue operating a community paramedicine program in an area where a private ambulance company had been providing the service under HWPP #173, the local EMS agency would first have to give the local fire departments or other public agencies the right of first refusal, which could result in the private ambulance company no longer being able to participate in the program it was helping to test.
   2. Hospice service should be clarified. Of the five listed specialties, four are described in ways that clearly identify the concept behind the pilot project of the same name. However, “providing hospice services to treat patients in their homes” does not reference the fact that this pilot concept was limited to 911 response in order to avoid transport to an emergency department. As written, it could be interpreted as authorizing a much broader form of hospice services. Similarly, as noted above, this bill makes a distinction between the 911 response-related specialty of alternate destination, and non-911 community paramedicine services. This bill treats the hospice specialty in the same way as other non-911 specialties, giving public agencies preference. The author should consider amending the bill to treat hospice the same way it treats the alternate destination specialties, and to make clear that it is not intended to provide all hospice services, but is limited to 911 response calls in the same manner as what was tested in HWPP #173.
   3. Prescribing membership of a voluntary EMCC. This bill requires that the county EMCC include an additional eight specified members if the local EMS agency develops a community paramedicine program. However, while existing law permits a county to establish this advisory committee, there is no requirement that an EMCC be established, nor is there any currently prescribed membership should a county choose to establish such a committee. If the intent of the author is to ensure an EMCC is established in a county where a community paramedicine program is established, this should be made clear.
   4. Should this bill have a sunset date? While this bill is based on pilot projects which have been evaluated, the number of patients enrolled in many of the projects was small, as were the total number of participating community paramedics. While the evaluation of HWPP #173 was positive, given the relatively small number of participating patients and community paramedics, and the relatively short time frame these projects have been in operation, particularly of the sobering center pilot project, the committee may wish to consider whether to include a sunset date, and a report back to the Legislature.

SUPPORT AND OPPOSITION:

Support: California Professional Firefighters (sponsor)

Local Health Plans of California

Oppose: California Ambulance Association

California Association for Health Services at Home

California Hospice & Palliative Care Association

California Nurses Association/National Nurses United

Individual Oppose

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