Existing law authorizes a county to develop an emergency medical services (EMS) program, and requires a county developing that program to designate a local EMS agency. Existing law authorizes a local EMS agency to develop a community paramedicine or triage to alternate destination program that, among other things, selects providers to triage individuals to mental health facilities and sobering centers as alternates to emergency departments. Existing law requires the Emergency Medical Services Authority to develop and, after approval by the Commission on Emergency Medical Services, adopt regulations and establish minimum standards for the development of those programs.

This bill would require the state to survey and analyze the facilities in each county that can serve as an alternate destination facility. The bill would require a local emergency medical services agency to develop an alternate destination facility plan with protocols for transporting an individual to an alternate destination facility instead of an emergency department. annually report to the Emergency Medical Services Authority regarding the development of triage to alternate destination programs in its jurisdiction, as specified.

Existing law authorizes a county to develop an emergency medical services (EMS) program, and requires a county developing that program to designate a local EMS agency. Existing law authorizes a local EMS agency to develop a community paramedicine or triage to alternate destination program that, among other things, selects providers to triage individuals to mental health facilities and sobering centers as alternates to emergency departments. Existing law requires the Emergency Medical Services Authority to develop and, after approval by the Commission on Emergency Medical Services, adopt regulations and establish minimum standards for the development of those programs.

This bill would require the state to survey and analyze the facilities in each county that can serve as an alternate destination facility. The bill would require a local emergency medical services agency to develop an alternate destination facility plan with protocols for transporting an individual to an alternate destination facility instead of an emergency department.

Existing law authorizes a county to develop an emergency medical services (EMS) program, and requires a county developing that program to designate a local EMS agency. Existing law authorizes a local EMS agency to develop a community paramedicine or triage to alternate destination program that, among other things, selects providers to triage individuals to mental health facilities and sobering centers as alternates to emergency departments. Existing law requires the Emergency Medical Services Authority to develop and, after approval by the Commission on Emergency Medical Services, adopt regulations and establish minimum standards for the development of those programs.

This bill would require the state to survey and analyze the facilities in each county that can serve as an alternate destination facility. The bill would require a local emergency medical services agency to develop an alternate destination facility plan with protocols for transporting an individual to an alternate destination facility instead of an emergency department.

Existing law requires the Department of Housing and Community Development to administer various programs intended to promote the development of housing, including the Multifamily Housing Program, pursuant to which the department provides financial assistance in the form of deferred payment loans to pay for the eligible costs of development for specified activities.

This bill would make a nonsubstantive change to the provision that names the Multifamily Housing Program.

Date of Hearing: May 8, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 2700

Author:(Gabriel) – As Amended Ver:April 16, 2024

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

SUMMARY:

This bill requires the state to conduct a comprehensive survey and analysis of facilities within each local emergency medical services agency (LEMSA) suitable for use as alternate destination facilities. This bill also requires the Emergency Medical Services Authority (EMSA) to publish on its website a detailed report outlining the current number, capacity, and types of facilities available for use as alternate destinations, along with the projected requirements to meet the current demand for services. This bill also requires a LEMSA to report, in its annual submission to EMSA, specified information regarding the development of triage to alternate destination programs in its jurisdiction.

FISCAL EFFECT:

EMSA reports it will aggregate and format information from 34 LEMSAs and 861 certified alcohol and other drug outpatient treatment programs, 185 narcotic treatment programs, 947 licensed residential alcoholism or drug abuse recovery or treatment facilities, 33 mental health rehabilitation centers, 34 psychiatric health facilities, 120 acute psychiatric hospitals, 2,637 community clinics, 163 federally qualified health centers, 282 rural health clinics, and a few other types of facilities. EMSA anticipates it will need two additional staff and will need to partner with the University of California to conduct a survey and analysis of potential alternate destination facilities. EMSA estimates personnel costs of $328,353 per year ongoing, and contract costs of $113,334 per year for three years, for total costs of $441,687 per year in fiscal years (FYs) 2024-25, 2025-26, and 2026-27, and $328,353 per year ongoing (General Fund).

According to the Legislative Analyst’s Office, the General Fund faces a structural deficit in the tens of billions of dollars over the next several fiscal years. 

COMMENTS:

1. Purpose. According to the author:

California is facing a behavioral health crisis and we have a responsibility to use all appropriate and effective tools to address it. AB 2700 ensures that local governments are prepared to provide these critical services to people in need. By planning ahead for the potential use of alternative destination sites, like crisis stabilization units and sobering centers, we will ensure we strike a balance to keep patients safe and healthy.

1. Background.

EMSA and LEMSAs. EMSA provides statewide oversight for the 34 local emergency medical services agencies or LEMSAs. Together they form the state’s pre-hospital emergency medical system. The pre-hospital emergency medical system and hospital emergency departments operate as separate and distinct entities, but are linked through policies, procedures and regulations. Collectively, these entities provide effective patient care from the initial notification of an emergency and response in the field to the time the emergency medical services (EMS) provider drops off the patient at the emergency department (ED) and returns to the community, while the patient receives evaluation, care and hospitalization, if needed.

The Community Paramedicine or Triage to Alternate Destination Act of 2020. AB 1544 (Gipson), Chapter 138, Statutes of 2020, defines “community paramedicine program” as consisting of one of two specialties: providing directly observed therapy to persons with tuberculosis in collaboration with a public health agency, or providing case management services to frequent EMS users in collaboration with, and by providing referral to, existing appropriate community resources. The act also defines “triage to alternate destination” as consisting of three specialties: providing care and comfort services to hospice patients in their homes in response to 911 calls; providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility, which can include an authorized mental health facility or an authorized sobering center; and providing transport services for patients who identify as veterans and desire transport to a local veterans administration ED for treatment.

As required by AB 1544, in November 2022 EMSA adopted regulations establishing minimum standards for the development of a community paramedicine or triage to alternate destination program. The regulations are based on and informed by the Community Paramedicine Pilot Program under the Department of Health Care Access and Information’s Health Workforce Pilot Project #173.

Over the last six years, California has been piloting programs to transport individuals in behavioral health crises to destinations such as crisis stabilization units and sobering centers. Advocates underscore the positive outcomes for not only patients with behavioral health, mental health and substance use disorders, but also on EMS systems. An independent evaluation found these pilots to be safe and effective means to improve the health and safety of the public. The evaluation found that 98% of patients transported to a mental health crisis center were effectively treated for their behavioral health needs. The evaluation also found ambulance patient offload times were considerably lower for transports to mental health crisis and sobering centers, allowing ambulance crews to respond more quickly to other 911 calls.

1. Prior Legislation.
   1. AB 767 (Gipson), Chapter 270, Statutes of 2023, adds short-term, post discharge follow-up for persons recently discharged from a hospital to the list of eligible community paramedicine services and extends, from January 1, 2024, to January 1, 2031, the sunset date of the community paramedicine program.
   2. AB 1544 (Gipson), Chapter 138, Statutes of 2020, enacts the Community Paramedicine or Triage to Alternate Destination Act of 2020, which permits LEMSAs, with approval by EMSA, to develop programs to provide community paramedic or triage to alternate destination services in one of the following specialties: (1) providing directly observed tuberculosis therapy; (2) providing case management services to frequent emergency medical services users; (3) providing hospice services to treat patients in their homes; and, (4) providing patients with transport to an alternate destination, which can either be an authorized mental health facility, or an authorized sobering center. The provisions of AB 1544 sunset on January 1, 2024.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 22, 2024

ASSEMBLY COMMITTEE ON EMERGENCY MANAGEMENT

Freddie Rodriguez, Chair

ABPCA Bill Id:AB 2700 (

Author:Gabriel) – As Amended Ver:April 16, 2024

SUBJECT: Emergency medical services: alternate destinations

SUMMARY: Expands the definition of an authorized sobering center to include a facility operated by a federally qualified health center. Requires the state to survey and analyze the facilities in each county that could serve as an alternate destination facility. Requires the Emergency Medical Services Authority (EMSA) to publish a report that provides each local emergency services agency (LEMSA) with the current number, capacity and type of alternate destination facilities. Requires a LEMSA, as part of their annual plan submission to EMSA, to include additional information regarding their alternate destination programs, as specified. Specifically, this bill:

1. Expands the definition of an authorized sobering center to include a facility operated by a federally qualified health center, including clinics, as specified.
2. Requires the state to survey and analyze the facilities in each county that can serve as an alternate destination facility. Requires EMSA to publish a report on its internet website that provides each LEMSA with the current number, capacity, and type of alternate destination facilities, as well as the needed number, capacity, and type of alternate destination facilities necessary to meet current demand for services.
   
3. Requires a LEMSA to include, as part of its annual plan submission to EMSA, the following information regarding their triage to alternate destination program:

(a) An assessment of the population within the local EMS agency that has access to a triage to alternate destination program.

(b) Information regarding behavioral health crisis facility types in the jurisdiction, as specified, that the local EMS agency would like to request EMSA evaluate for future authorization as an alternate destination.

(c) Information regarding barriers to implementing the triage to alternate destination program.

1. Requires a LEMSA without a triage to alternate destination program to include, as part of its annual plan submission to EMSA, the following information:

(a) Information regarding availability of authorized mental health facilities or authorized sobering centers in the jurisdiction.

(b) Information regarding the willingness of potential triage to alternate destination providers in the jurisdiction.

(c) Information regarding behavioral health crisis facility types in the jurisdiction not otherwise authorized under Section 1812 or 1813 that the local EMS agency would like to request the authority evaluate for future authorization as an alternate destination.

(d) Efforts to identify funding to support alternate destination programs.

(e) Efforts to coordinate with and discuss these programs with the county department or departments relative to behavioral health within the jurisdiction.

(f) Estimated number of behavioral health 911 calls made in the jurisdiction that the emergency medical services system responds to.

(g) Identify whether there are any mobile integrated health or other programs operating in the jurisdiction that utilize higher medical authorities to triage patients to authorized mental health facilities or authorized sobering centers.

(h) Identify any personnel limitations that exist for emergency medical services

providers operating advanced life support services within the jurisdiction of the local

EMS agency.

EXISTING LAW:

1. Establishes the Emergency Medical Services Authority, under the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, which is responsible for the coordination of various state activities concerning emergency medical services. (Health and Safety Code Section 1797)
2. Requires, among other things, EMSA to develop planning and implementation guidelines for EMS systems, provide technical assistance to existing agencies, counties, and cities for the purpose of developing the components of EMS systems, and receive plans for the implementation of EMS and trauma care systems from local EMS agencies. (Health and Safety Code Section 1797.103-105)
3. Provides each county may develop an emergency medical services program. Each county developing such a program shall 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 and Safety Code Section 1797.200)
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. (Health and Safety Code Section 1797.84)
5. Establishes the Health Workforce Pilot Projects (HWPP) in the Department of Health Care Access and Information (HCAI). (Health and Safety Code Section 128125)
6. Establishes the Community Paramedicine or Triage to Alternate Destination Act of 2020 and defines “community paramedicine program” and “triage to alternate destination,” as specified. (Health and Safety Code Section 1800 )
7. Requires EMSA to develop regulations that establish minimum standards for the development of a community paramedicine or triage to alternate destination program, and requires the Commission on EMS to review and approve the regulations. (Health and Safety Code Section 1830)
8. 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. (Welfare and Institutions Code Section 5000)
   

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

COMMENTS:

Purpose of the bill: According to the author, “California is facing a behavioral health crisis and we have a responsibility to use all appropriate and effective tools to address it. AB 2700 ensures that local governments are prepared to provide these critical services to people in need. By planning ahead for the potential use of alternative destination sites, like crisis stabilization units and sobering centers, we will ensure we strike a balance to keep patients safe and healthy.”

Equity impact: According to the author’s staff, “For decades, California has failed to provide necessary mental health crisis services amidst this growing mental health crisis, which disproportionately impacts people of color. Disparities in access to and quality of behavioral health care have historically impacted Black and Brown communities, connecting people directly with a behavioral health facility is essential to help break the barriers to access. In recent years, California has invested tremendous resources into a robust crisis care continuum in an effort to decriminalize our behavioral health care. These investments have included implementing the 988 crisis line, adding a statewide mobile crisis team Medi-Cal benefit, and building out our crisis infrastructure through the Behavioral Health Continuum Infrastructure Program (BHCIP). Expanding triage to alternative destination programs is a key piece of the crisis care continuum and is essential to the expansion of our behavioral health care. Health crises deserve a health response.”

EMSA and LEMSAs: EMSA provides statewide oversight for the 33 local emergency medical services agencies or LEMSAs. Together they form the state’s pre-hospital emergency medical system. The pre-hospital emergency medical system and hospital emergency departments operate as separate and distinct entities, but are linked through policies, procedures and regulations. Collectively, these entities provide effective patient care from the initial notification of an emergency and response in the field to the time the EMS provider drops off the patient at the emergency department and returns to the community, while the patient receives evaluation, care and hospitalization, if needed.

AB 1544, the Community Paramedicine or Triage to Alternate Destination Act of 2020: This act defines “community paramedicine program” as consisting of one of two specialties: providing directly observed therapy to persons with tuberculosis in collaboration with a public health agency; and, providing case management services to frequent EMS users in collaboration with, and by providing referral to, existing appropriate community resources. The act also defines “triage to alternate destination” as consisting of three specialties: providing care and comfort services to hospice patients in their homes in response to 911 calls; providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility, which can include an authorized mental health facility or an authorized sobering center; and, providing transport services for patients who identify as veterans and desire transport to a local veterans administration ED for treatment.

EMSA regulations: In November 2022 EMSA adopted regulations as required by AB 1544 which establish minimum standards for the development of a community paramedicine or triage to alternate destination program, and are based upon, and informed by, the Community Paramedicine Pilot Program under HWPP #173, and the protocols and operation of the pilot projects such as alternate destinations for behavioral health, mental health, and sobering centers.

Impact on patient outcomes and EMS systems: Advocates of the bill underscore the positive outcomes for not only patients with behavioral health, mental health and substance use disorders, but also the overall positive impact on EMS systems with triage to alternate destination programs. Over the last 6 years, California has been piloting programs to transport individuals in behavioral health crises to destinations such as crisis stabilization units and sobering centers as appropriate.

An independent UCSF evaluation found these pilots to be safe and effective means to improve the health and safety of the public. The evaluation found that 98% of patients transported to a mental health crisis center were effectively treated for their behavioral health needs.

The evaluation also found that ambulance patient offload times were considerably lower for transports to mental health crisis and sobering centers, meaning ambulance crews can respond more quickly to other 911 calls. This bill establishes greater information sharing between LEMSAs and EMSA regarding successful implementation of triage to alternate destination programs, as well as barriers to establish such programs.

Arguments in support: The Steinberg Institute writes in support, “The Steinberg Institute is proud to sponsor AB 2700, also known as the From Crisis to Care Act, which focuses on reducing unnecessary and traumatic emergency department visits for people in behavioral health crises. California is increasingly focusing on delivering compassionate care to individuals in behavioral health crises. In 2022, California passed AB 988 to set up an alternative crisis response system to 911. We have invested billions into behavioral health crisis facilities infrastructure through the Behavioral Health Continuum Infrastructure Program, with billions more potentially on the horizon with Proposition 1. Through CalAIM, we have added sobering centers as an optional new benefit and added Medi-Cal coverage for these vital services. At the same time, over the last 6 years, California has been piloting programs to transport individuals in behavioral health crises to destinations such as crisis stabilization units and sobering centers as appropriate.

An independent UCSF evaluation found these pilots to be safe and effective means to improve the health and safety of the public. The evaluation found that 98% of patients transported to a mental health crisis center were effectively treated for their behavioral health needs. The evaluation also found that ambulance patient offload times were considerably lower for transports to mental health crisis and sobering centers, meaning ambulance crews can respond more quickly to other 911 calls.

The California Hospital Association writes in support, “All Californians should have access to behavioral health crisis prevention, response, and care services. While EDs are an important access point, alternative facilities and community services are just as — if not more — effective.

The Substance Abuse and Mental Health Services Administration (SAMHSA) reported in 2020 that a high proportion of people in crisis who are evaluated for hospitalization can be safely cared for in a crisis facility and the outcomes for these individuals are at least as good as hospital care. Additionally, the cost to provide care at a crisis care facility is substantially less than the costs of inpatient care and accompanying ED “medical clearance” charges. By expanding care options for those with mental or behavioral health care needs, AB 2700 would push each community to create new and improved strategies that better meet Californians’ growing behavioral health care needs.”

Double referral: This bill passed, as amended, the Assembly Committee on Health on April 16, 2024 with a vote of 13-0-3.

Prior legislation:

AB 767 (Gipson), Chapter 270, Statutes of 2023. Adds short-term, post discharge follow-up for persons recently discharged from a hospital to the list of eligible community paramedicine services and requires the Emergency Medical Authority (EMSA) to amend existing regulations to include that service. Extends the sunset date of the community paramedicine program from January 1, 2024, to January 1, 2031.

AB 40 (Rodriguez), Chapter 793, Statutes of 2023. Requires EMSA to develop a system for an electronic signature for use between the emergency department and ambulance personnel that captures the points in time when a hospital receives notification of ambulance arrival and when transfer of care is executed for documentation of ambulance patient offload time (APOT). AB 40 requires EMSA to develop a statewide standard of 30 minutes, 90% of the time for APOT, and requires a general acute care hospital to develop an APOT reduction protocol, that addresses specified factors. Finally, AB 40 requires EMSA, on or after March 1, 2024, to monitor APOT for each facility that is required to report.

AB 1544 (Gipson), Chapter 138, Statutes of 2020. Enacted the Community Paramedicine or Triage to Alternate Destination Act of 2020, which permits LEMSAs, with approval by EMSA, to develop programs to provide community paramedic or triage to alternate destination services in one of the following specialties: (1) providing directly observed tuberculosis therapy; (2) providing case management services to frequent emergency medical services users; (3) providing hospice services to treat patients in their homes; and, (4) providing patients with transport to an alternate destination, which can either be an authorized mental health facility, or an authorized sobering center. AB 1544’s provisions sunset on January 1, 2024.

REGISTERED SUPPORT / OPPOSITION:

Support

Steinberg Institute (Sponsor)

California Alliance for Youth and Community Justice

California Association of Alcohol and Drug Program Executives

California Consortium of Addiction Programs and Professionals

California Association of Local Behavioral Health Boards and Commissions

California Hospital Association

Californians for Safety and Justice

Californians United for a Responsible Budget

Ella Baker Center for Human Rights

Freedom 4 Youth

Initiate Justice

MILPA Collective

National Sobering Collaborative

Phoenix House of California

Prosecutors Alliance of California

Rubicon Programs

Santa Cruz Barrios Unidos

Sharp HealthCare

The Kennedy Forum

The Miles Hall Foundation

WellSpace Health

Youth Leadership Institute

Opposition

None on file.

Analysis Prepared by: Mike Dayton / E.M. / (916) 319-3802

Date of Hearing: April 9, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 2700 (

Author:(Gabriel) – As Amended Ver:April 1, 2024

SUBJECT: Emergency medical services: alternate destinations.

SUMMARY: Requires the state to survey and analyze the facilities in each county that could serve as an alternate destination facility. Requires the Emergency Medical Services Authority (EMSA) to publish a report that provides each local emergency services agency (LEMSA) with the current number, capacity and type of alternate destination facilities. Requires a LEMSA, in consultation with the county, to develop an alternate destination facility plan with protocols for transporting an individual to an alternate destination facility instead of an emergency department (ED). Specifically, this bill:

1. Requires the state to survey and analyze the facilities in each county that can serve as an alternate destination facility. Requires EMSA to publish a report on its internet website that provides each LEMSA with the current number, capacity, and type of alternate destination facilities, as well as the needed number, capacity, and type of alternate destination facilities necessary to meet current demand for services.
   
2. Requires a LEMSA, in consultation with the county department or departments relevant to behavioral health within its jurisdiction, to develop an alternate destination facility plan with protocols for transporting an individual to an alternate destination facility instead of an ED.
   
3. Requires the plan developed pursuant to 2) above, to do both of the following:
   1. Ensure that transportation to an ED is no longer the default protocol for an individual in need of mental or behavioral health care services; and,
   2. Utilize existing facilities identified in the report published pursuant to 1) above.
      
4. Defines the following for purposes of this bill:
   1. “Alternate destination facility” means a treatment location that serves as an alternative to an ED, including a mental health facility or sobering center;
   2. “EMS” means emergency medical services;
   3. “Mental health facility” means a facility that is licensed or certified as a mental health treatment facility or a hospital, and can include a licensed psychiatric hospital, a licensed psychiatric health facility, or a certified crisis stabilization unit. Specifies that an authorized mental health facility can also be a psychiatric health facility licensed by the State Department of Health Care Services (DHCS).
   4. “Sobering center” means a noncorrectional facility that is staffed at all times with at least one registered nurse, that provides a safe, supportive environment for intoxicated individuals to become sober, and that meets any of the following requirements:
      1. The facility is a federally qualified health center, including a clinic exempt from licensure by the Department of Public Health (DPH);
      2. The facility is certified by DHCS Substance Use Disorder Compliance Division to provide outpatient, nonresidential detoxification services; or,
      3. The facility meets the National Sobering Collaborative standard of care.
         

EXISTING LAW:

1. Establishes EMSA, which is responsible for the coordination and integration of all state activities concerning EMS), including the establishment of minimum standards, policies, and procedures. [Health and Safety Code (HSC) §1797.100, et seq.]
2. Authorizes counties to develop an EMS program and designate a LEMSA responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations. [HSC §1797.200, et seq.]
3. 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]
4. Establishes the Health Workforce Pilot Projects (HWPP) in the Department of Health Care Access and Information (HCAI) 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.]
5. Permits HCAI 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 HCAI. [HSC §128135 and §128140]
6. Establishes the Community Paramedicine or Triage to Alternate Destination Act of 2020. Defines “community paramedicine program” as consisting of one of two specialties: providing directly observed therapy to persons with tuberculosis in collaboration with a public health agency; and, providing case management services to frequent EMS users in collaboration with, and by providing referral to, existing appropriate community resources. Defines “triage to alternate destination” as consisting of three specialties: providing care and comfort services to hospice patients in their homes in response to 911 calls; providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility, which can include an authorized mental health facility or an authorized sobering center; and, providing transport services for patients who identify as veterans and desire transport to a local veterans administration ED for treatment. [HSC §1800 et seq.]
7. Requires EMSA to develop regulations that establish minimum standards for the development of a community paramedicine or triage to alternate destination program, and requires the Commission on EMS to review and approve the regulations. Requires the regulations to be based upon, and informed by, the Community Paramedicine Pilot Program under HWPP #173, and the protocols and operation of the pilot projects approved under HWPP #173. [HSC §1830]
   
8. Requires hospital EDs, 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 ED. [HSC §1317, et seq.]
   
9. 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. [Welfare and Institutions Code (WIC) §5000, et seq.]
10. Authorizes, under Section 5150 of the WIC, 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. [WIC §5150]
    

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, California is facing a behavioral health crisis and we have a responsibility to use all appropriate and effective tools to address it. This bill ensures that local governments are prepared to provide these critical services to people in need. The author concludes that by planning ahead for the potential use of alternative destination sites, like crisis stabilization units and sobering centers, we will ensure we strike a balance to keep patients safe and healthy
2. BACKGROUND.
   1. The Community Paramedicine or Triage to Alternate Destination Act. In November of 2014, the Office of Statewide Health Planning and Development (which has since been merged into HCAI) approved an application from EMSA to establish HWPP #173, to test different concepts of community paramedicine. Initially, HWPP #173 encompassed 13 sites testing six concepts, with more sites added over the ensuring years, including a seventh concept testing transporting patients to a sobering center. HWPP #173 was extended multiple times, and over the years, some sites were added while other pilot project sites were shut down. The following are the concepts that were tested by this pilot project:
      1. 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;
      2. Frequent EMS Users, intended to provide case management to frequent 911 callers and frequent visitors to EDs by connecting them with primary care, behavioral health, housing, and social services;
      3. Directly Observed Therapy for Tuberculosis, where the paramedic dispensed medication and observed patients taking them to assure effective treatment;
      4. 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 ED;
      5. 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 ED;
      6. 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 ED; and,
      7. 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 ED.

After several legislative attempts to authorize these concepts in statute to make them permanent, AB 1544 (Gipson), Chapter 138, Statutes of 2020, was signed into law in 2020, creating the Community Paramedicine or Triage to Alternate Destination Act. Of the seven concepts, all were included in AB 1544 except for two: Alternate Destination – Urgent Care, which was not included because all project sites testing this concept had closed down; and Post-Discharge, Short-Term Follow-up, which had mixed results in early test sites, described in more detail in 3) below. While Post-Discharge, Short-Term Follow-up was not included as part of the Community Paramedicine or Triage to Alternate Destination Act, AB 1544 did include a provision permitting the two remaining pilot project sites in that specialty at the time, Solano County and the City of Alameda (since closed down), to continue operating until January 1, 2024.

AB 1544 required EMSA to adopt regulations implementing the bill, and included a provision that permitted the existing pilot programs to continue operating while the regulations were being developed until up to one year after EMSA adopted the regulations. Once the regulations were adopted, EMSA could approve additional community paramedic or alternative destination programs that were developed by LEMSAs, and the existing pilot programs would have to be approved to continue after the initial year. However, regulations were not finalized until October 31, 2022, and because the entire program was scheduled to sunset in January of 2024, no new programs were added, and some pilot project sites are no longer operating. AB 1544 extended the sunset on these pilot programs to January 1, 2031.

b) 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 LEMSA 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.

c) Status of Community Paramedicine and Triage to alternate Destination Projects. According to the final report by the independent evaluation team at UC San Francisco, with data through September of 2022, the alternate destination for mental health patients have reduced the number of persons in EDs who only need mental health services.

Alternate Destination – Mental Health. The four projects enrolled 8,332 persons between September 2015 and September 2022; 2,757 were enrolled after AB 1544 implementation. Across the four Alternate Destination –Mental Health projects, large percentages of patients screened were transported to the mental health crisis center rather than an ED:

• • 1. Stanislaus’ project transported 28% of the 1,997 patients screened to a mental health crisis center between September 2015 and its closure in July 2022.
    2. Fresno’s project transported 33% of the 23,152 patients screened between July 2018 and September 2022 to a mental health crisis center.
    3. Gilroy’s project transported 40% of the 287 patients screened between November 2018 through September 2022 to a mental health crisis center.
    4. Los Angeles’ project transported 27% of the 302 patients screened between June 2019 and June 2020 to a mental health crisis center. Some patients who were eligible for transport to a mental health crisis center were taken to an ED instead because the crisis center was at capacity.

Transport of patients directly to a mental health crisis center has reduced the number of persons in EDs who only need mental health services, which may help reduce ED overcrowding. Only 2% of patients enrolled in the three Alternate Destination–Mental Health projects (n = 160) were transferred from the mental health crisis center to an ED within six hours of admission. None of the transfers involved a life-threatening condition, and only 20 of the patients transferred to an ED were admitted for inpatient medical care. Ambulance patient offload times at mental health crisis centers are substantially shorter than at EDs in the same communities, which enables 911 response crews who transport patients to the crisis centers to return to the field to respond to other 911 calls more quickly. Law enforcement officers report that having community paramedics available enhances their ability to respond effectively to persons with mental health needs.

Alternate Destination – Sobering Center. The three Alternate Destination– Sobering Center projects enrolled 3,906 persons from February 2017 through September 2022; 847 of those patients were enrolled after AB 1544 implementation. Most patients (3,810) were enrolled in San Francisco’s Alternate Destination– Sobering Center project. Los Angeles’ Alternate Destination– Sobering Center project has enrolled 96 people since it launched in late June of 2019, however no new patients have enrolled since early 2020. The Santa Clara County EMS Agency and the Gilroy Fire Department’s Alternate Destination – Sobering Center project closed in May 2022. Ninety-eight point three percent of patients enrolled in San Francisco’s Alternate Destination – Sobering Center project were treated safely and effectively at the sobering center. Only 64 patients (1.6%) were transferred to an ED within six hours of admission to the sobering center, and only three (0.1%) were rerouted from the sobering center to an ED because registered nurses at the sobering center declined to accept them. Only 12 patients were admitted to a hospital for inpatient medical care. None of the patients enrolled in Los Angeles’ Alternate Destination – Sobering Center project were transferred to an ED within six hours of admission. The 90th percentile ambulance patient offload time at San Francisco’s sobering center is 17 minutes, whereas the 90th percentile ambulance patient offload time for patients transported to all EDs in San Francisco is 34 minutes. This enables 911 response crews who transport patients to the crisis centers to return to the field to respond to other 911 calls more quickly. Data were not available for Los Angele’s Alternate Destination – Sobering Center project

1. SUPPORT. The Steinberg Institute (SI) is the sponsor of this bill and states that California is increasingly focusing on delivering compassionate care to individuals in behavioral health crises. In 2022, California passed AB 988 (Bauer-Kahan), Chapter 747, Statutes of 2022, to set up an alternative crisis response system to 911. SI notes that we have invested billions into behavioral health crisis facilities infrastructure through the Behavioral Health Continuum Infrastructure Program, with billions more potentially on the horizon with Proposition 1, and through CalAIM, we have added sobering centers as an optional new benefit and added Medi-Cal coverage for these vital services. SI states that at the same time, over the last six years, California has been piloting programs to transport individuals in behavioral health crises to destinations such as crisis stabilization units and sobering centers as appropriate. An independent University of California, San Francisco evaluation found these pilots to be safe and effective means to improve the health and safety of the public. The evaluation found that 98% of patients transported to a mental health crisis center were effectively treated for their behavioral health needs. The evaluation also found that ambulance patient offload times were considerably lower for transports to mental health crisis and sobering centers, meaning ambulance crews can respond more quickly to other 911 calls. In order to maximize California’s substantial investments in addressing the behavioral health crisis care, expanding access to these services is critical. Now is the time to expand access to alternative destinations. A key aspect to the expansion of these services is having an assessment of the available behavioral health facilities, and their needs along with a plan to transport people in need of care to these facilities.
   
2. OPPOSITION. The California Nurses Association (CNA) is opposed to this bill and states that the proposed new triage to alternate destination program for patients with behavioral health needs would dangerously eliminate access to emergency medical care for patients with behavioral health needs. In other words, under this bill, people who call 911 but have or appear to have any mental or behavioral health need will no longer by default be provided with emergency care at an ED. CNA contends that this bill requires that LEMSAs develop triage to alternate destination plans that “[e]nsure that transportation to an ED is no longer the default protocol for an individual in need of mental or behavioral health care services.” (emphasis added).
   
3. OPPOSE UNLESS AMENDED. The California Chapter of the American College of Emergency Physicians (CalACEP) is opposed to this bill unless it is amended and notes that when the successful pilots were taken to scale statewide, it was important to ensure that they operate under the same training and conditions. CalACEP states that in 2020, they took what they learned from those pilots and used them to inform their co-sponsorship of AB 1544 which was signed into law and, among other things, allowed LEMSAs to create programs to transport 911 callers to mental health facilities rather than EDs. Last year they co-sponsored AB 767 (Gipson), Chapter 270, Statutes of 2023, to extend the sunset on that law. CalACEP notes that the framework established by those bills and enacted in HSC Sections 1800-1857 created statewide standards for training of EMS personnel – including required hours and curriculum content, patient safety protocols, minimum standards, anti-discrimination protections, and reporting and data collection provisions. However, as currently written, this bill proposes to transport 911 callers to mental health facilities entirely outside of that existing patient safety framework. CalACEP also contends that the bill specifically directs LEMSAs to “ensure that transportation to an ED is no longer the default protocol for an individual in need of mental or behavioral health care service,” and that this language statutorily overrides medical decision-making. CalACEP concludes that creating a new untested system with no standards or requirements for training of EMS personnel, patient safety protocols, or anti-discrimination protections, as currently proposed by this bill is an unnecessary threat to public safety.
   
   The California Professional Firefighters (CPF) are oppose unless amended and notes that reviewing data from the pilot programs, alternate destination programs have proved successful in diverting non-emergent patients from the emergency room, with only 2% of patients transported to either a mental health crisis center or a sobering center requiring subsequent transport to the ED. The current regulatory system is built to ensure this type of patient outcome. CPF believes that by placing the requirements of this bill in code sections separate from the pilot programs will have the effect of mandating the adoption of alternate destination programs in each community without the statutory structure that is currently contained in Health and Safety Code and subsequent regulations adopted by EMSA.
   
4. PREVIOUS LEGISLATION.
   1. AB 767 adds short-term, post discharge follow-up for persons recently discharged from a hospital to the list of eligible community paramedicine services and requires the Emergency Medical Authority (EMSA) to amend existing regulations to include that service. Extends the sunset date of the community paramedicine program from January 1, 2024, to January 1, 2031.
   2. AB 1544 establishes the Community Paramedicine or Triage to Alternate Destination Act of 2020, which permits LEMSAs, with approval by EMSA, to develop programs to provide community paramedic or triage to alternate destination services in one of the following specialties: i) providing directly observed tuberculosis therapy; ii) providing case management services to frequent emergency medical services users; iii) providing hospice services to treat patients in their homes; and, iv) providing patients with transport to an alternate destination, which can either be an authorized mental health facility, or an authorized sobering center.
5. DOUBLE REFERRAL. This bill is double referred, upon passage in this Committee, this bill will be re-referred to the Assembly Committee on Emergency Management.
6. SUGGESTED AMENDMENTS. As currently drafted this bill places a statewide expansion of the triage to alternate destination provisions of the Community Paramedicine Pilot Project. In order to address concerns raised by Cal-ACEP and the California Professional Firefighters, the author may wish to consider amending this bill to clarify that the alternate destination programs implemented by this bill will be subject to existing EMSA regulations.

REGISTERED SUPPORT / OPPOSITION:

Support

California Association of Alcohol and Drug Program Executives, INC.
California Consortium of Addiction Programs and Professionals
California Hospital Association
Californians for Safety and Justice
Ella Baker Center for Human Right
Freedom 4 Youth
Initiate Justice
MILAP Collective
National Sobering Collaborative
Phoenix Houses of California, INC.
Prosecutors Alliance of California, a Project of Tides Advocacy
Rubicon Programs
Steinberg Institute
The California Association of Local Behavioral Health Boards and Commissions
The Kennedy Forum
The Miles Hall Foundation
Wellspace Health
Youth Leadership Institute

Opposition

California Nurses Association

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