Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, governs local emergency medical services (EMS) systems. The Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act establish the Emergency Medical Services Authority, which is responsible for the coordination and integration of EMS systems. Existing law makes a violation of the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act or regulations adopted pursuant to the act punishable as a misdemeanor.

Existing law, the Community Paramedicine or Triage to Alternate Destination Act of 2020 (the act), authorizes a local EMS agency to develop a community paramedicine or triage to alternate destination program, as defined, to provide specified community paramedicine services. The act requires the 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 act prohibits a person or organization from providing community paramedicine or triage to alternate destination services or representing, advertising, or otherwise implying that it is authorized to provide those services unless it is expressly authorized by a local EMS agency to provide those services as part of a program approved by the authority. The act also prohibits a community paramedic or a triage paramedic from providing their respective services unless the community paramedic or triage paramedic has been certified and accredited to perform those services and is working as an employee of an authorized provider. The act is repealed on January 1, 2024.

This bill would extend the act until January 1, 2031. The bill would expand the allowable community paramedicine services program specialties to include providing short-term, postdischarge followup for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible. The bill would require, on or before January 1, 2025, the authority to amend regulations to include sufficient state-level program oversight that would allow for local EMS agencies to develop community paramedicine programs, as specified.

Because a violation of the act is punishable as a misdemeanor, and this bill would create new requirements within the act and extend the operation of the act, this bill would expand an existing crime, thereby imposing a state-mandated local program.

This bill would extend the authorization for specified community paramedicine short-term, postdischarge followup pilot programs to continue operations from January 1, 2024, until the regulations described above become effective. The bill would repeal certain provisions within the act requiring the authority to seek federal or private funding for those pilot programs. The bill would repeal a provision within the act requiring a local EMS agency to facilitate funding discussions between specified entities to support the implementation of the local EMS agencys community paramedicine or triage to alternate destination program. The bill would extend a requirement for a county board of supervisors or mayor to establish an emergency medical care committee to advise a local EMS agency that elects to develop a program pursuant to the act from January 1, 2024, to January 1, 2031.

Existing law requires the authority to contract with an independent third party to prepare a final report on the results of the community paramedicine or triage to alternate destination programs. Existing law requires the authority to submit the report to the relevant policy committees of the Legislature on or before April 1, 2023.

This bill would instead require the authority to prepare the final report and submit the report on or before April 1, 2028.

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 Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act establish the Emergency Medical Services Authority, which is responsible for the coordination and integration of EMS systems. Existing law makes a violation of the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act or regulations adopted pursuant to the act punishable as a misdemeanor.

Existing law, the Community Paramedicine or Triage to Alternate Destination Act of 2020 (the act), authorizes a local EMS agency to develop a community paramedicine or triage to alternate destination program, as defined, to provide specified community paramedicine services. The act requires the 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 act prohibits a person or organization from providing community paramedicine or triage to alternate destination services or representing, advertising, or otherwise implying that it is authorized to provide those services unless it is expressly authorized by a local EMS agency to provide those services as part of a program approved by the authority. The act also prohibits a community paramedic or a triage paramedic from providing their respective services unless the community paramedic or triage paramedic has been certified and accredited to perform those services and is working as an employee of an authorized provider. The act is repealed on January 1, 2024.

This bill would extend the act until January 1, 2031. The bill would expand the allowable community paramedicine services program specialties to include providing short-term, postdischarge followup for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible. The bill would require, on or before January 1, 2025, the authority to amend regulations to include sufficient state-level program oversight that would allow for local EMS agencies to develop community paramedicine programs, as specified.

Because a violation of the act is punishable as a misdemeanor, and this bill would create new requirements within the act and extend the operation of the act, this bill would expand an existing crime, thereby imposing a state-mandated local program.

This bill would extend the authorization for specified community paramedicine short-term, postdischarge followup pilot programs to continue operations from January 1, 2024, until the regulations described above become effective. The bill would repeal certain provisions within the act requiring the authority to seek federal or private funding for those pilot programs. The bill would repeal a provision within the act requiring a local EMS agency to facilitate funding discussions between specified entities to support the implementation of the local EMS agencys community paramedicine or triage to alternate destination program. The bill would extend a requirement for a county board of supervisors or mayor to establish an emergency medical care committee to advise a local EMS agency that elects to develop a program pursuant to the act from January 1, 2024, to January 1, 2031.

Existing law requires the authority to contract with an independent third party to prepare a final report on the results of the community paramedicine or triage to alternate destination programs. Existing law requires the authority to submit the report to the relevant policy committees of the Legislature on or before April 1, 2023.

This bill would instead require the authority to prepare the final report and submit the report on or before April 1, 2028.

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 Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act establish the Emergency Medical Services Authority, which is responsible for the coordination and integration of EMS systems. Existing law makes a violation of the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act or regulations adopted pursuant to the act punishable as a misdemeanor.

Existing law, the Community Paramedicine or Triage to Alternate Destination Act of 2020 (the act), authorizes a local EMS agency to develop a community paramedicine or triage to alternate destination program, as defined, to provide specified community paramedicine services. The act requires the 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 act prohibits a person or organization from providing community paramedicine or triage to alternate destination services or representing, advertising, or otherwise implying that it is authorized to provide those services unless it is expressly authorized by a local EMS agency to provide those services as part of a program approved by the authority. The act also prohibits a community paramedic or a triage paramedic from providing their respective services unless the community paramedic or triage paramedic has been certified and accredited to perform those services and is working as an employee of an authorized provider. The act is repealed on January 1, 2024.

This bill would extend the act until January 1, 2031. The bill would expand the allowable community paramedicine services program specialties to include providing short-term, postdischarge followup for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible. The bill would require, on or before January 1, 2025, the authority to amend regulations to include that program specialty. sufficient state-level program oversight that would allow for local EMS agencies to develop community paramedicine programs, as specified.

Because a violation of the act is punishable as a misdemeanor, and this bill would create new requirements within the act and extend the operation of the act, this bill would expand an existing crime, thereby imposing a state-mandated local program.

This bill would extend the authorization for specified community paramedicine short-term, postdischarge followup pilot programs to continue operations from January 1, 2024, until the regulations described above become effective. The bill would repeal certain provisions within the act requiring the authority to seek federal or private funding for those pilot programs. The bill would extend a requirement within the act for the authority to contract with an independent third party to prepare a final report on the results of the community paramedicine or triage to alternate destination programs from April 1, 2023, to April 1, 2028. The bill would repeal a provision within the act requiring a local EMS agency to facilitate funding discussions between specified entities to support the implementation of the local EMS agencys community paramedicine or triage to alternate destination program. The bill would extend a requirement for a county board of supervisors or mayor to establish an emergency medical care committee to advise a local EMS agency that elects to develop a program pursuant to the act from January 1, 2024, to January 1, 2031.

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 Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act establish the Emergency Medical Services Authority, which is responsible for the coordination and integration of EMS systems. Existing law makes a violation of the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act or regulations adopted pursuant to the act punishable as a misdemeanor.

Existing law, the Community Paramedicine or Triage to Alternate Destination Act of 2020 (the act), authorizes a local EMS agency to develop a community paramedicine or triage to alternate destination program, as defined, to provide specified community paramedicine services. The act requires the 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 act prohibits a person or organization from providing community paramedicine or triage to alternate destination services or representing, advertising, or otherwise implying that it is authorized to provide those services unless it is expressly authorized by a local EMS agency to provide those services as part of a program approved by the authority. The act also prohibits a community paramedic or a triage paramedic from providing their respective services unless the community paramedic or triage paramedic has been certified and accredited to perform those services and is working as an employee of an authorized provider. The act is repealed on January 1, 2024.

This bill would extend the act until January 1, 2031. The bill would expand the allowable community paramedicine services program specialties to include providing short-term, postdischarge followup for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible. The bill would require, on or before January 1, 2025, the authority to amend regulations to include that program specialty.

Because a violation of the act is punishable as a misdemeanor, and this bill would create new requirements within the act and extend the operation of the act, this bill would expand an existing crime, thereby imposing a state-mandated local program.

This bill would repeal certain provisions within the act authorizing extend the authorization for specified community paramedicine short-term, postdischarge followup pilot programs. programs to continue operations from January 1, 2024, until the regulations described above become effective. The bill would repeal certain provisions within the act requiring the authority to seek federal or private funding for those pilot programs. The bill would extend a requirement within the act for the authority to contract with an independent third party to prepare a final report on the results of the community paramedicine or triage to alternate destination programs from April 1, 2023, to April 1, 2028.

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 Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act establish the Emergency Medical Services Authority, which is responsible for the coordination and integration of EMS systems. Existing law makes a violation of the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act or regulations adopted pursuant to the act punishable as a misdemeanor.

Existing law, the Community Paramedicine or Triage to Alternate Destination Act of 2020 (the act), authorizes a local EMS agency to develop a community paramedicine or triage to alternate destination program, as defined, to provide specified community paramedicine services. The act requires the 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 act prohibits a person or organization from providing community paramedicine or triage to alternate destination services or representing, advertising, or otherwise implying that it is authorized to provide those services unless it is expressly authorized by a local EMS agency to provide those services as part of a program approved by the authority. The act also prohibits a community paramedic or a triage paramedic from providing their respective services unless the community paramedic or triage paramedic has been certified and accredited to perform those services and is working as an employee of an authorized provider. The act is repealed on January 1, 2024.

This bill would extend the act until January 1, 2031. The bill would expand the allowable community paramedicine services program specialties to include providing short-term, postdischarge followup for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible. The bill would require, on or before January 1, 2025, the authority to amend regulations to include that program specialty.

Because a violation of the act is punishable as a misdemeanor, and this bill would create new requirements within the act and extend the operation of the act, this bill would expand an existing crime, thereby imposing a state-mandated local program.

This bill would repeal certain provisions within the act authorizing community paramedicine short-term, postdischarge followup pilot programs. The bill would extend a requirement within the act for the authority to contract with an independent third party to prepare a final report on the results of the community paramedicine or triage to alternate destination programs from April 1, 2023, to April 1, 2028.

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.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 767

Author:(Gipson)

As Amended Ver:September 1, 2023

Majority vote

SUMMARY

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.

Senate Amendments

1. Authorize a community paramedicine short-term, post-discharge follow-up pilot program that was approved on or before January 1, 2019, to continue operation until one year after the regulations required by this bill become effective.
2. Repeal a provision in existing law requiring a local emergency medical services (EMS) agency to facilitate funding discussions between specified entities to support the implementation of the local EMS agency's community paramedicine or triage to alternate destination program.
3. Extend the requirement for EMS agency to provide a report to the Legislature from April 1, 2023, to April 1, 2028.

COMMENTS

AB 1544 (Gipson), Chapter 138, Statutes of 2020, enacts the Community Paramedicine or Triage to Alternate Destination Act of 2019, which permits local emergency medical services agencies (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.

Since its initial approval for the original one-year period, Health Workforce Pilot Program (HWPP) #173 has been renewed five times. The last renewal was codified under AB 1544, and unless renewed again, it is scheduled to end on December 30, 2023. Thirteen pilot projects were launched from June through October of 2015. Seven more projects began enrolling patients in 2017, 2018, and 2019. Five projects have closed, and one has suspended operations. Two Post-Discharge – Short-Term Follow-Up projects closed due to lack of local resources and one has suspended operations. The three Alternate Destination – Urgent Care projects closed due to low enrollment. The pilot projects enrolled 10,855 persons through September 30, 2020.

The HWPP regulations require organizations that sponsor pilot projects to retain an independent evaluator to assess trainee performance, patient acceptance, and cost-effectiveness. The Philip R. Lee Institute for Health Policy Studies and Healthforce Center at University of Californis, San Francisco conducted the most recent evaluation, released February 18 2021, which was funded by the California Health Care Foundation. Key findings are as follows:

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.

According to the Author

Today's existing healthcare model of directing all transports to hospitals has created congestion in emergency departments (EDs). Community Paramedicine can play an important role in improving California's health care delivery system and is an innovative model of care. The author notes that this program seeks to improve the effectiveness and efficiency of health care delivery by using specially trained paramedics in partnership with other health care providers to address the needs of local health care systems. The pilot program started by AB 1544 (Gipson), Chapter 138, Statutes of 2020, has been extremely successful but, due to a lengthy development process the community paramedicine and triage to alternate destination regulations did not take effect until November 1, 2022. The author concludes that an extension of the sunset is needed for the programs to be fully established and given a fair chance.

Arguments in Support

The California Professional Firefighters, a sponsor of this bill, state that community paramedicine programs as implemented first under pilot programs throughout the state and then fully authorized by AB 1544 have shown considerable positive impacts in the communities where they operate. These programs empower trained paramedics to provide additional, much needed services to their communities, reducing the strain on EDs and facilitating improved access to services such as mental health crisis centers and targeted interventions for frequent EMS users. When communities are asked who they trust, firefighters are always ranked among the most trustworthy leaders, making them well-positioned to utilize existing resources and apply expanded protocols developed by medical and behavioral health experts to improve patient care throughout the jurisdictions they serve.

The California Chapter of the American College of Emergency Physicians (California ACEP) also a sponsor of this bill states that, in 2020, AB 1544 was signed into law to expand EMT scope of practice to authorize several of the concepts tested in the pilots including transporting patients to sobering centers and mental health facilities rather than EDs. That law will sunset on December 31, 2023 unless legislation is passed this year to extend the sunset. There are several innovative community paramedicine programs currently being operated in cities throughout the state providing improved care to frequent 911 utilizers, hospice patients, and patients who would benefit from the continuation of these programs.

Concerns

The California Nurses Association (CNA) has submitted a letter of concern regarding this bill. CNA is concerned that the expansion of post-discharge follow-ups as a form of EMS would erode the scope of nursing practice and result in delays in patients receiving nursing care through home health programs. CNA states that it is unclear how EMS personnel would be able to assess when nursing care is required for patients and communicate the need for nursing care to providers. Hospitals may also take advantage of the expansion of post-discharge programs by shifting nursing care and wound care away from home health registered nurses to EMS personnel who provide post-discharge services. EMS personnel would be asked to make assessments on when acute or home health nursing care is necessary, but this nursing care assessment should always be performed by registered nurses.

Arguments in Opposition

The California Association for Health Services at Home (CAHSAH), opposes this bill and states that it is an expansion of the scope of paramedics into licensed home care, home health and hospice services by individuals who are neither trained, licensed, nor regulated to provide such services. This bill gives broad authority to local EMS authorities to create standards for treating vulnerable patients in the home by individuals who do not have the training and expertise to care for the specific needs of these patients. This bill will allow paramedics to provide home care, home health and hospice services without having to meet the same licensure, regulatory or personnel training requirements as licensed home care, home health and hospice agencies. CAHSAH notes that training and scope of practice are the major differences between paramedics and nurses. Nurses complete a nursing diploma program including an associate or bachelor's degree in nursing, which takes two to four years to complete. Although paramedics and nurses perform some of the same tasks, such as starting an intravenous line, nurses have an extremely broad scope of practice that includes emergency, acute, convalescent and outpatient care, while paramedics are limited to pre-hospital emergency care. Community paramedics do not have the training to assess adverse health effects of medication interactions as their training in pharmacology is extremely limited.

The Department of Finance is opposed to this bill because it results in General Fund impacts not included in the Administration's spending plan.

FISCAL COMMENTS

According to the Senate Appropriations Committee, unknown General Fund costs, likely hundreds of thousands annually through 2030-31, for EMSA for state staffing and data system needs.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner Horvath, Wendy Carrillo, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

ASSEMBLY FLOOR: 76-0-4

YES: Addis, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

ABS, ABST OR NV: Aguiar-Curry, Kalra, Mathis, Papan

SENATE FLOOR: 38-0-2

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ABS, ABST OR NV: Dahle, Jones

UPDATED

VERSION: September 1, 2023

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0001690

 THIRD READING  

Bill No: AB 767

Author: Gipson (D)

Amended: 9/1/23 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 6/21/23

AYES: Eggman, Nguyen, Glazer, Gonzalez, Hurtado, Limón, Menjivar, Roth, Rubio, Wahab, Wiener

NO VOTE RECORDED: Grove

SENATE APPROPRIATIONS COMMITTEE: 6-0, 9/1/23

AYES: Portantino, Ashby, Bradford, Seyarto, Wahab, Wiener

NO VOTE RECORDED: Jones

ASSEMBLY FLOOR: 76-0, 5/25/23 - See last page for vote

SUBJECT: Community Paramedicine or Triage to Alternate Destination Act

SOURCE: California Chapter of the American College of Emergency Physicians

California Professional Firefighters

DIGEST:

This bill extends the sunset date of the Community Paramedicine or Triage to Alternate Destination Act of 2020, from January 1, 2024 to January 1, 2031, and adds short-term, post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition to the list of program specialties that can be part of a community paramedicine program.

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. 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. 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. 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 emergency department for treatment. [HSC §1800 et seq.]
6. Requires EMSA to develop regulations that establish minimum standards for the development of a community paramedicine or triage to alternate destination program, and requires the Commission on EMS to review and approve the regulations. 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]

This bill:

1. Extends the sunset date of the Community Paramedicine or Triage to Alternate Destination Act of 2020, from January 1, 2024 to January 1, 2031.
2. Extends the date by which EMSA is required to submit a final report on the results of the community paramedicine or triage to alternate destination programs, from April 1, 2023 to April 1, 2028, and repeals the requirement that EMSA contract with an independent third-party evaluator to develop the report.
3. Adds short-term, post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition to the list of program specialties that can be part of a community paramedicine program developed by a local EMS agency, including collaboration with, and providing referral to home health services when eligible.
4. Requires EMSA, by January 1, 2025, to amend regulations adopted pursuant to the community paramedicine program to include sufficient state-level program oversight that would allow for local EMS agencies to develop community paramedicine programs.
5. Revises a provision of law that permits a short-term, post-discharge follow-up pilot program that was approved on or before January 1, 2019, and was continuing to enroll patients as of January 1, 2019, to continue operation, by allowing the pilot program to continue until one year after regulations are adopted by EMSA pursuant to 4) above, rather than only until January 1, 2024.
6. Repeals a requirement that local EMS agencies facilitate funding discussions between a community paramedicine provider and public or private health system participants to support the implementation of the local EMS agency’s community paramedicine programs.

Comments

1. Author’s statement. According to the author, today's existing healthcare model of directing all transports to hospitals has created congestion in emergency departments. Community paramedicine can play an important role in improving California's healthcare delivery system and is an innovative model of care. This program seeks to improve the effectiveness and efficiency of healthcare delivery by using specially trained paramedics in partnership with other healthcare providers to address the needs of local healthcare systems. The pilot program started by AB 1544 (Gipson, Chapter 138, Statutes of 2020) has been extremely successful, but due to a lengthy development process, the community paramedicine and triage to alternate destination regulations did not have enough time to evaluate the merits of the program fully. Therefore, an extension of the sunset is needed for the programs to be fully established and given a thorough evaluation. In addition, this bill authorizes a short-term post-discharge follow-up program. This home-based follow-up care for people recently discharged from a hospital due to a chronic condition reduces their risk of readmission and improves their ability to manage their condition.
2. Background on the pilot project that led to the creation of 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 emergency departments 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 emergency department;
   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 emergency department;
   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 emergency department; 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 emergency department.

After several legislative attempts to authorize these concepts in statute to make them permanent, AB 1544 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 local EMS agencies, 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 sunsets in January of 2024, no new programs have been added, and some pilot project sites are no longer operating.

1. Background and evaluation on Post-Discharge, Short-Term Follow-up pilot program. There were a total of five post-discharge project sites that operated at some point leading up to the passage of AB 1544: in the City of Alameda, at UCLA-Glendale, and in the counties of Butte, San Bernardino, and Solano. The UCLA-Glendale site closed in 2016 because the partner fire department was unwilling to continue funding the project. The Butte County site stopped enrolling patients in November of 2018, partly due to poor results. The San Bernardino County project closed in 2019 due to loss of hospital partner participation. The Alameda City project closed in 2020 due to the change of ownership of Alameda City Hospital. Only the Solano County project remains in operation.
   
   According to the final update from the independent evaluation of the pilot project sites that is being conducted by the Healthforce Center and the Phillip R. Lee Institute for Health Policy Studies at the UC San Francisco, the Post-Discharge, Short-Term Follow-up projects have enrolled 1,833 patients. Butte’s project had by far the most at 1,001 patients, and Alameda’s had the smallest at 140 patients. The evaluation stated that post discharge projects have improved patient safety by performing home visits within a few days of a patient’s hospital discharge to ensure that patients understand their discharge instructions, are taking medications as prescribed, have sufficient refills to manage their conditions, have follow-up visits scheduled with their physicians, and are adhering to any dietary restrictions pertinent to the management of their condition. Across all of the post discharge projects, the 30-day readmission rates for persons with the chronic conditions that are the target are below the partner hospital’s historical readmission rate for that condition. Butte’s heart failure patients were the only group whose all-cause 30-day readmission rate was higher than the historical rate. In response to these findings, Butte changed its protocol from phone calls to in-person visits in November 2017, but its readmission rate for patients with heart failure did not decrease. The evaluation stated that through September 2020, the five post discharge projects avoided potential costs of approximately $1.4 million, the majority of which would accrue to Medicare. Participating hospitals also reduced their risk of incurring Medicare penalties for excessive readmissions. With regard to the only remaining post discharge project, which this bill would allow to continue while regulations are developed to ultimately allow additional programs, Solano County has enrolled a total of 124 heart failure patients, and 167 patients with chronic obstructive pulmonary disease. With regard to the heart failure patients, only 12 were readmitted (9.7%), which is below the historical readmission rate of 22.1% for their partner hospital. For the chronic obstructive pulmonary disease patients, 18 were readmitted (10.8%), which is also below the 18.9% rate for their partner hospital. Looking just at the number of patients enrolled since AB 1544 took effect in January of 2021, Solano enrolled 8 heart failure patients (through September of 2022), with 1 of those patients being readmitted, and 10 chronic obstructive pulmonary disease patients, with none of those being readmitted.
2. Report on the other program specialties in the Community Paramedicine or Triage to Alternate Destination Act. According to the final report by the independent evaluation team at UC San Francisco, with data through September of 2022, all of the five program specialties that were included in AB 1544, which this bill is extending the sunset date on until January 1, 2031, continue to be successful. The frequent EMS user projects have achieved large reductions in the number of 911 calls made on behalf of their clients. Patients enrolled in the directly observed therapy for tuberculosis project are more likely to receive all doses of tuberculosis medications. Among hospice patients enrolled in the pilot project, the percentage of 911 calls that resulted in transport to an emergency department decreased from 80% to 38%. The alternate destination for mental health patients have reduced the number of persons in emergency departments who only need mental health services. And finally, only 1.6% of the 3,810 patients enrolled in San Francisco’s alternate destination to a sobering center project were transferred to an emergency department within six hours of admission, and the Los Angeles project, while it only enrolled 96 patients since it launched in June 2019 and none since early 2020, no patients had been transferred to an emergency department.
3. Letter of Concern: The California Nurses Association (CNA) submitted a letter of concern, stating that the expansion of post-discharge follow-ups as a form of EMS would erode the scope of nursing practice and result in delays in patients receiving nursing care through home health programs. CNA states it is unclear how EMS personnel would be able to assess when nursing care is required for patients, and that hospitals may also take advantage of the expansion of post-discharge programs by shifting nursing care and wound care away from home health registered nurses to EMS personnel. CNA cited data it obtained from HCAI that they stated showed that emergency department visits actually increased at the post-discharge pilot project sites, rather than the decrease showed by the independent evaluator at UC San Francisco. CNA requests that the addition of the post-discharge, short-term follow-up program from the bill.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to the Senate Appropriations Committee, unknown General Fund costs, likely hundreds of thousands annually through 2030-31, for the Emergency Medical Services Authority (EMSA) for state staffing and data system needs.

SUPPORT: (Verified 8/21/23)

California Chapter of the American College of Emergency Physicians (co-source)
California Professional Firefighters (co-source)

California Fire Chiefs Association

California Hospital Association
California Medical Association

City and County of San Francisco
City of San Diego
Emergency Nurses Association, California State Council

Fire Districts Association of California
LeadingAge California

OPPOSITION: (Verified 8/21/23)

California Ambulance Association

California Association for Health Services at Home

Department of Finance

ARGUMENTS IN SUPPORT: This bill is co-sponsored by the California Professional Firefighters (CPF) and the California Chapter of the American College of Emergency Physicians (California ACEP). According to CPF state that the pilot programs established throughout California have demonstrated the ongoing effectiveness and community benefits of both community paramedicine programs and triage to alternate destinations. At a time when the healthcare system is struggling with overcrowded emergency departments and overloaded EMS systems, it is critical to use all tools necessary to ease the burden and provide patients with the best possible care. Extending the sunset date of AB 1544 by seven years will give local agencies the assurance they need to move forward with establishing these programs and provide access to these proven models to more communities throughout the state. California ACEP states there are several innovative community paramedicine programs currently being operated that are providing improved care to frequent 911 utilizers and other patients who would benefit from the continuation of these programs. The California Emergency Nurses Association states in support that multiple studies have shown that quality of care decreases in crowded emergency departments, and that an alternative destination program will assist with current overcrowding by decreasing the volume of patients in the emergency department. The expansion of the community paramedicine programs provides an appropriate, safe way of managing these types of patients, including follow up for persons recently discharged from a hospital.

ARGUMENTS IN OPPOSITION: The California Association for Health Services at Home (CAHSAH) states in opposition that the expansion of the allowable community paramedicine programs to include providing short-term, post-discharge follow-up for persons recently discharged from a hospital is an expansion of the scope of paramedics 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 this bill gives broad authority to local EMS authorities to create standards for treating patients in the home by individuals who do not have the training and expertise to care the specific needs of these patients. This bill will allow paramedics to provide home health care without having to meet the same licensure, regulatory, or personnel training requirements as licensed home care, home health and hospice agencies. CAHSAH states that the data collected from these pilot projects focused on cost savings, not patient outcomes, and without an equal emphasis on safe and effective treatment, the end result could be cost savings for hospitals and insurers, but a lower standard of care for these most vulnerable patients.

ASSEMBLY FLOOR: 76-0, 5/25/23

AYES: Addis, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

NO VOTE RECORDED: Aguiar-Curry, Kalra, Mathis, Papan

Prepared by: Vincent D. Marchand / HEALTH / (916) 651-4111

9/2/23 12:11:04

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 767 (Gipson) - Community Paramedicine or Triage to Alternate Destination Act

Bill Summary:

AB 767 would extend the sunset date of the Community Paramedicine or Triage to Alternate Destination Act of 2020, from January 1, 2024 to January 1, 2031, and add short-term, post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition to the list of program specialties that can be part of a community paramedicine program.

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

The following information is revised to reflect amendments

adopted by the committee on September 1, 2023

Fiscal Impact:

Unknown General Fund costs, likely hundreds of thousands annually through 2030-31, for the Emergency Medical Services Authority (EMSA) for state staffing and data system needs.

Author Amendments:

Author amendments, among other provisions, extend a requirement that the county establish an emergency medical care committee to advise the local emergency medical services (EMS) agency on the development of the program under the act, from January 1, 2024 to January 1, 2031; remove the requirement that EMSA contract with an independent third-party when preparing a required report; and delete the current statutory requirement for local EMS agencies to facilitate funding discussions.

-- END --

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 767 (Gipson) - Community Paramedicine or Triage to Alternate Destination Act

Bill Summary:

AB 767 would extend the sunset date of the Community Paramedicine or Triage to Alternate Destination Act of 2020, from January 1, 2024 to January 1, 2031, and add short-term, post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition to the list of program specialties that can be part of a community paramedicine program.

Fiscal Impact:

The Emergency Medical Services Authority (EMSA) estimates General Fund costs of $484,000 in 2023-24 and $404,000 in 2024-25 and ongoing through 2030-31, for state staffing and data system needs.

Background:

The EMSA 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.

Current law establishes the Community Paramedicine or Triage to Alternate Destination Act of 2020. Under this law, “community paramedicine program” may consist 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. “Triage to alternate destination” may consist 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 emergency department for treatment.

Proposed Law:

Specific provisions of the bill would:

• Extend the sunset date of the Community Paramedicine or Triage to Alternate Destination Act of 2020, from January 1, 2024 to January 1, 2031.
• Extend the date by which EMSA is required to submit a final report on the results of the community paramedicine or triage to alternate destination programs, from April 1, 2023 to April 1, 2028.
• Add short-term, post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition to the list of program specialties that can be part of a community paramedicine program developed by a local EMS agency, including collaboration with, and providing referral to home health services when eligible.
• Require EMSA, by January 1, 2025, to amend regulations adopted pursuant to the community paramedicine program to include the short-term, post-discharge follow-up program specialty.
• Extend the authorization for certain community paramedicine short-term, postdischarge followup pilot programs to continue operations, as specified.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Susan Talamantes Eggman, Chair

BILL NO: AB 767

SUBJECT: Community Paramedicine or Triage to Alternate Destination Act

SUMMARY:

Extends the sunset date of the Community Paramedicine or Triage to Alternate Destination Act of 2020, from January 1, 2024 to January 1, 2031, and adds short-term, post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition to the list of program specialties that can be part of a community paramedicine program.

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. 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 emergency department 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]

This bill:

1. Extends the sunset date of the Community Paramedicine or Triage to Alternate Destination Act of 2020, from January 1, 2024 to January 1, 2031.
2. Extends the date by which EMSA is required to submit a final report on the results of the community paramedicine or triage to alternate destination programs, from April 1, 2023 to April 1, 2028.
3. Adds short-term, post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition to the list of program specialties that can be part of a community paramedicine program developed by a local EMS agency, including collaboration with, and providing referral to home health services when eligible.
4. Requires EMSA, by January 1, 2025, to amend regulations adopted pursuant to the community paramedicine program to include the short-term, post-discharge follow-up program specialty.
5. Repeals a provision of law permitting a short-term, post-discharge follow-up pilot program that was approved on or before January 1, 2019, and was continuing to enroll patients as of January 1, 2019, to continue operation until January 1, 2024.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, EMSA will require one specialist for the EMS Systems Division and an analyst for the EMS Personnel Division. The staff would promulgate regulations, establish uniform standards for implementation and oversight of community paramedicine programs, meet with stakeholders, facilitate an advisory committee, perform site visits to field programs, and approve local community paramedicine plans.

EMSA also reports the EMS Systems and Personnel unit data collection processes might have to be altered as the community paramedicine program matures. EMSA would request funds for software and data standards revisions.

EMSA estimates total costs of $443,000 in fiscal year (FY) 2023-24 and $383,000 in FY 2024-25 and annually through FY 2030-31 (General Fund).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, today's existing healthcare model of directing all transports to hospitals has created congestion in emergency departments. Community paramedicine can play an important role in improving California's healthcare delivery system and is an innovative model of care. This program seeks to improve the effectiveness and efficiency of healthcare delivery by using specially trained paramedics in partnership with other healthcare providers to address the needs of local healthcare systems. The pilot program started by AB 1544 (Gipson, Chapter 138, Statutes of 2020) has been extremely successful, but due to a lengthy development process, the community paramedicine and triage to alternate destination regulations did not have enough time to evaluate the merits of the program fully. Therefore, an extension of the sunset is needed for the programs to be fully established and given a thorough evaluation. In addition, this bill authorizes a short-term post-discharge follow-up program. This home-based follow-up care for people recently discharged from a hospital due to a chronic condition reduces their risk of readmission and improves their ability to manage their condition.
2. Background on the pilot project that led to the creation of 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 emergency departments 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 emergency department;
   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 emergency department;
   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 emergency department; 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 emergency department.

After several legislative attempts to authorize these concepts in statute to make them permanent, AB 1544 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 local EMS agencies, 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 sunsets in January of 2024, no new programs have been added, and some pilot project sites are no longer operating.

1. Background and evaluation on Post-Discharge, Short-Term Follow-up pilot program. There were a total of five post-discharge project sites that operated at some point leading up to the passage of AB 1544: in the City of Alameda, at UCLA-Glendale, and in the counties of Butte, San Bernardino, and Solano. The UCLA-Glendale site closed in 2016 because the partner fire department was unwilling to continue funding the project. The Butte County site stopped enrolling patients in November of 2018, partly due to poor results. The San Bernardino County project closed in 2019 due to loss of hospital partner participation. The Alameda City project closed in 2020 due to the change of ownership of Alameda City Hospital. Only the Solano County project remains in operation.
   
   According to the final update from the independent evaluation of the pilot project sites that is being conducted by the Healthforce Center and the Phillip R. Lee Institute for Health Policy Studies at the UC San Francisco, the Post-Discharge, Short-Term Follow-up projects have enrolled 1,833 patients. Butte’s project had by far the most at 1,001 patients, and Alameda’s had the smallest at 140 patients. The evaluation stated that post discharge projects have improved patient safety by performing home visits within a few days of a patient’s hospital discharge to ensure that patients understand their discharge instructions, are taking medications as prescribed, have sufficient refills to manage their conditions, have follow-up visits scheduled with their physicians, and are adhering to any dietary restrictions pertinent to the management of their condition. Across all of the post discharge projects, the 30-day readmission rates for persons with the chronic conditions that are the target are below the partner hospital’s historical readmission rate for that condition. Butte’s heart failure patients were the only group whose all-cause 30-day readmission rate was higher than the historical rate. In response to these findings, Butte changed its protocol from phone calls to in-person visits in November 2017, but its readmission rate for patients with heart failure did not decrease. The evaluation stated that through September 2020, the five post discharge projects avoided potential costs of approximately $1.4 million, the majority of which would accrue to Medicare. Participating hospitals also reduced their risk of incurring Medicare penalties for excessive readmissions. With regard to the only remaining post discharge project, which this bill would allow to continue while regulations are developed to ultimately allow additional programs, Solano County has enrolled a total of 124 heart failure patients, and 167 patients with chronic obstructive pulmonary disease. With regard to the heart failure patients, only 12 were readmitted (9.7%), which is below the historical readmission rate of 22.1% for their partner hospital. For the chronic obstructive pulmonary disease patients, 18 were readmitted (10.8%), which is also below the 18.9% rate for their partner hospital. Looking just at the number of patients enrolled since AB 1544 took effect in January of 2021, Solano enrolled 8 heart failure patients (through September of 2022), with 1 of those patients being readmitted, and 10 chronic obstructive pulmonary disease patients, with none of those being readmitted.
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. Report on the other program specialties in the Community Paramedicine or Triage to Alternate Destination Act. According to the final report by the independent evaluation team at UC San Francisco, with data through September of 2022, all of the five program specialties that were included in AB 1544, which this bill is extending the sunset date on until January 1, 2031, continue to be successful. The frequent EMS user projects have achieved large reductions in the number of 911 calls made on behalf of their clients. Patients enrolled in the directly observed therapy for tuberculosis project are more likely to receive all doses of tuberculosis medications. Among hospice patients enrolled in the pilot project, the percentage of 911 calls that resulted in transport to an emergency department decreased from 80% to 38%. The alternate destination for mental health patients have reduced the number of persons in emergency departments who only need mental health services. And finally, only 1.6% of the 3,810 patients enrolled in San Francisco’s alternate destination to a sobering center project were transferred to an emergency department within six hours of admission, and the Los Angeles project, while it only enrolled 96 patients since it launched in June 2019 and none since early 2020, no patients had been transferred to an emergency department.
4. Related legislation. AB 40 (Rodriguez) 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 40 is pending in this Committee.
   
   AB 379 (Rodriguez) requires a local EMS agency to adopt policies and procedures for calculating and reporting APOT, and to establish a process for hospitals and ambulance providers to review and validate the reported data. AB 379 requires a local EMS agency to develop and submit an EMS system plan to EMSA, and requires this plan to be made accessible. AB 379 is pending in this Committee.
5. Prior legislation. AB 450 (Gonzalez, Chapter 463, Statutes of 2021) establishes the Paramedic Disciplinary Review Board (Board), and provides the Board with final authority to impose discipline or revoke a paramedic license, or deny a license application, which is currently vested in the Director of the Emergency Medical Services Authority.
   
   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.
   
   AB 1795 (Gipson of 2018) would have authorized 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. AB 1795 would have authorized a city or county to designate, and contract with, a sobering center to receive patients, and would establish sobering center standards. AB 1795 was held on the Assembly Appropriations Committee suspense file.
   
   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.
6. Support. This bill is co-sponsored by the California Professional Firefighters (CPF) and the California Chapter of the American College of Emergency Physicians (California ACEP). According to CPF state that the pilot programs established throughout California have demonstrated the ongoing effectiveness and community benefits of both community paramedicine programs and triage to alternate destinations. At a time when the healthcare system is struggling with overcrowded emergency departments and overloaded EMS systems, it is critical to use all tools necessary to ease the burden and provide patients with the best possible care. Extending the sunset date of AB 1544 by seven years will give local agencies the assurance they need to move forward with establishing these programs and provide access to these proven models to more communities throughout the state. California ACEP states there are several innovative community paramedicine programs currently being operated that are providing improved care to frequent 911 utilizers and other patients who would benefit from the continuation of these programs. The California Emergency Nurses Association states in support that multiple studies have shown that quality of care decreases in crowded emergency departments, and that an alternative destination program will assist with current overcrowding by decreasing the volume of patients in the emergency department. The expansion of the community paramedicine programs provides an appropriate, safe way of managing these types of patients, including follow up for persons recently discharged from a hospital.
7. Opposition. The California Association for Health Services at Home (CAHSAH) states in opposition that the expansion of the allowable community paramedicine programs to include providing short-term, post-discharge follow-up for persons recently discharged from a hospital is an expansion of the scope of paramedics 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 this bill gives broad authority to local EMS authorities to create standards for treating patients in the home by individuals who do not have the training and expertise to care the specific needs of these patients. This bill will allow paramedics to provide home health care without having to meet the same licensure, regulatory, or personnel training requirements as licensed home care, home health and hospice agencies. CAHSAH states that the data collected from these pilot projects focused on cost savings, not patient outcomes, and without an equal emphasis on safe and effective treatment, the end result could be cost savings for hospitals and insurers, but a lower standard of care for these most vulnerable patients.
8. Letter of concern. The California Nurses Association (CNA) submitted a letter of concern, stating that the expansion of post-discharge follow-ups as a form of EMS would erode the scope of nursing practice and result in delays in patients receiving nursing care through home health programs. CNA states it is unclear how EMS personnel would be able to assess when nursing care is required for patients, and that hospitals may also take advantage of the expansion of post-discharge programs by shifting nursing care and wound care away from home health registered nurses to EMS personnel. CNA cited data it obtained from HCAI that they stated showed that emergency department visits actually increased at the post-discharge pilot project sites, rather than the decrease showed by the independent evaluator at UC San Francisco. CNA requests that the addition of the post-discharge, short-term follow-up program from the bill.
9. Amendments. Because this bill is adding short-term, post-discharge follow-up to the Community Paramedicine or Triage to Alternate Destination Act, there is a corresponding provision deleting the ability of existing short-term, post-discharge follow-up program sites to continue operating until January 1, 2024 (which is down to just Solano County). However, because this bill also requires EMSA to adopt regulations on the short-term, post-discharge follow-up program specialty, the author may wish to add back in a provision allowing the Solano County site to continue operating until one year following the adoption of regulations, similar to how the other project sites were handled in AB 1544.

SUPPORT AND OPPOSITION:

Support: California Chapter of the American College of Emergency Physicians (co-sponsor)
California Professional Firefighters (co-sponsor)
California Medical Association
City of San Diego
Emergency Nurses Association, California State Council
LeadingAge California

Oppose: California Association for Health Services at Home

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 767

Author:(Gipson)

As Introduced Ver:February 13, 2023

Majority vote

SUMMARY

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.

Major Provisions

COMMENTS

AB 1544 (Gipson), Chapter 138, Statutes of 2020, enacts the Community Paramedicine or Triage to Alternate Destination Act of 2019, which permits local emergency medical services agencies (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.

Since its initial approval for the original one-year period, Health Workforce Pilot Program (HWPP) #173 has been renewed five times. The last renewal was codified under AB 1544, and unless renewed again, it is scheduled to end on December 30, 2023. Thirteen pilot projects were launched from June through October of 2015. Seven more projects began enrolling patients in 2017, 2018, and 2019. Five projects have closed, and one has suspended operations. Two Post-Discharge – Short-Term Follow-Up projects closed due to lack of local resources and one has suspended operations. The three Alternate Destination – Urgent Care projects closed due to low enrollment. The pilot projects enrolled 10,855 persons through September 30, 2020.

The HWPP regulations require organizations that sponsor pilot projects to retain an independent evaluator to assess trainee performance, patient acceptance, and cost-effectiveness. The Philip R. Lee Institute for Health Policy Studies and Healthforce Center at UC San Francisco conducted the most recent evaluation, released February 18 2021, which was funded by the California Health Care Foundation. Key findings are as follows:

1. Post-Discharge Short-term follow-up. From June 2015 through September 2020, the five Post-Discharge – Short-Term Follow-Up projects have enrolled 1,814 patients. Butte's project had the largest enrollment (1,001 patients), and Alameda's had the smallest (140 patients). The Post-Discharge – Short-Term Follow-Up projects have improved patient safety by performing home visits within a few days of a patient's hospital discharge to ensure that patients understand their discharge instructions, are taking medications as prescribed, have sufficient refills to manage their conditions, have follow-up visits scheduled with their physicians and are adhering to any dietary restrictions pertinent to the management of their condition. Through September 2020, the five Post-Discharge – Short-Term Follow-Up projects avoided potential costs of approximately $1.4 million, the majority of which (61%) would accrue to Medicare.
2. Frequent emergency medical services (EMS) User. The three Frequent EMS User projects have enrolled 481 people from July 2015 through September 2020 and have achieved large reductions in the number of 911 calls made on behalf of their clients and the number of transports to emergency departments (EDs). Frequent EMS User projects have linked patients to organizations that provide primary care, dental care, mental health services, substance abuse treatment, food, housing, transportation, and other services that can address their needs more effectively than the EMS system.
3. Directly Observed Therapy for Tuberculosis (TB). The TB project enrolled 52 persons from June 2015 through September 2020. Most patients are enrolled for multiple months because treatment for TB typically spans six to nine months. Community paramedics dispensed appropriate doses of TB medications, and their TB patients did not experience side effects any more frequently than typically associated with TB treatment. Twelve patients were admitted to a hospital in the period during which the project has been in operation, but only one patient was hospitalized for TB. This patient needed intravenous medication to treat TB meningitis, which had been diagnosed prior to enrollment in the program. People with TB who received directly observed treatment (DOT) from community paramedics were more likely to receive all doses of TB medications prescribed by the TB clinic physician than people who received DOT from the TB clinic's staff.
4. Hospice. The Hospice project enrolled 422 persons between August 2015 and September 2020 and reduced the likelihood that patients who preferred treatment at home were transported to an ED, which could result in loss of hospice benefits. No patients were denied transport to an ED when it was indicated and consistent with the patient's preference. Among hospice patients enrolled in the pilot project, the percentage of 911 calls that resulted in transport to an ED decreased from 80% to 28%. The Hospice project avoided potential costs of $318,097 by reducing ambulance transports and ED visits.
5. Alternate Destination – Mental Health. The four Alternate Destination – Mental Health projects enrolled 5,093 persons between September 2015 and September 2020. Across the four projects, 27% to 44% of patients screened were transported to the mental health crisis center rather than an ED. In Stanislaus County, an additional 29% could have been transported to the crisis center if the county had more inpatient psychiatric beds or if the crisis center accepted people with private insurance or Medicare. 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 can help reduce ED overcrowding.
6. Alternate Destination – Sobering Center. The three Alternate Destination – Sobering Center projects enrolled 2,945 persons from February 2017 through September 2020. Four hundred and twelve patients (14%) were treated at the sobering center more than once. Most patients (2,849) were enrolled in San Francisco's Alternate Destination – Sobering Center project. Los Angeles' project has enrolled 96 people since it launched in late June of 2019. The Santa Clara County EMS Agency and the Gilroy Fire Department's Alternate Destination – Sobering Center project has not enrolled any patients as of September 2020. 98.2% of patients enrolled in San Francisco's Alternate Destination – Sobering Center project were treated safely and effectively at the sobering center. Only 51 patients (1.7%) were transferred to an ED within six hours of admission to the sobering center, and only two (0.1%) were rerouted from the sobering center to an ED because registered nurses at the sobering center declined to accept them. Only five patients were admitted to a hospital for inpatient medical care.
7. Paramedic training. 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 LEMSA. A core curriculum was developed that the Department of Health Care Access and Information 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.

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.

According to the Author

Today's existing healthcare model of directing all transports to hospitals has created congestion in EDs. Community Paramedicine can play an important role in improving California's health care delivery system and is an innovative model of care. The author notes that this program seeks to improve the effectiveness and efficiency of health care delivery by using specially trained paramedics in partnership with other health care providers to address the needs of local health care systems. The pilot program started by AB 1544 (Gipson), Chapter 138, Statutes of 2020, has been extremely successful but, due to a lengthy development process the community paramedicine and triage to alternate destination regulations did not take effect until November 1, 2022. The author concludes that an extension of the sunset is needed for the programs to be fully established and given a fair chance.

Arguments in Support

The California Professional Firefighters, a sponsor of this bill, state that community paramedicine programs as implemented first under pilot programs throughout the state and then fully authorized by AB 1544 have shown considerable positive impacts in the communities where they operate. These programs empower trained paramedics to provide additional, much needed services to their communities, reducing the strain on EDs and facilitating improved access to services such as mental health crisis centers and targeted interventions for frequent EMS users. When communities are asked who they trust, firefighters are always ranked among the most trustworthy leaders, making them well-positioned to utilize existing resources and apply expanded protocols developed by medical and behavioral health experts to improve patient care throughout the jurisdictions they serve. Further, firefighters are positioned throughout the community 24/7 at strategically placed firehouses. As such, community paramedicine programs will allow for timely and improved access to essential services.

The California Chapter of the American College of Emergency Physicians (California ACEP) also a sponsor of this bill states that, in 2020, AB 1544 was signed into law to expand EMT scope of practice to authorize several of the concepts tested in the pilots including transporting patients to sobering centers and mental health facilities rather than EDs. That law will sunset on December 31, 2023 unless legislation is passed this year to extend the sunset. There are several innovative community paramedicine programs currently being operated in cities throughout the state providing improved care to frequent 911 utilizers, hospice patients, and patients who would benefit from the continuation of these programs. California ACEP notes that they are pleased to co-sponsor this bill to extend the sunset on this scope expansion while maintaining some statewide standards and important patient safety protections.

Concerns

The California Nurses Association (CNA) has submitted a letter of concern regarding this bill. CNA is concerned that the expansion of post-discharge follow-ups as a form of EMS would erode the scope of nursing practice and result in delays in patients receiving nursing care through home health programs. CNA states that it is unclear how EMS personnel would be able to assess when nursing care is required for patients and communicate the need for nursing care to providers. Hospitals may also take advantage of the expansion of post-discharge programs by shifting nursing care and wound care away from home health registered nurses to EMS personnel who provide post-discharge services. EMS personnel would be asked to make assessments on when acute or home health nursing care is necessary, but this nursing care assessment should always be performed by registered nurses. CNA contends that even the most well-intentioned EMS personnel would not be able to assess a patient's nursing care requirements of patients and would not know when nurses should be altered to intervene.

Arguments in Opposition

The California Association for Health Services at Home (CAHSAH), opposes this bill and states that it is an expansion of the scope of paramedics into licensed home care, home health and hospice services by individuals who are neither trained, licensed, nor regulated to provide such services. This bill gives broad authority to local EMS authorities to create standards for treating vulnerable patients in the home by individuals who do not have the training and expertise to care for the specific needs of these patients. Home care, home health and hospice agencies are explicitly regulated under California law, with home health and hospice services further regulated under the Medicare Conditions of Participation to ensure patient safety is not jeopardized. This bill will allow paramedics to provide home care, home health and hospice services without having to meet the same licensure, regulatory or personnel training requirements as licensed home care, home health and hospice agencies. CAHSAH notes that training and scope of practice are the major differences between paramedics and nurses. Nurses complete a nursing diploma program including an associate or bachelor's degree in nursing, which takes two to four years to complete. Although paramedics and nurses perform some of the same tasks, such as starting an intravenous line, nurses have an extremely broad scope of practice that includes emergency, acute, convalescent and outpatient care, while paramedics are limited to pre-hospital emergency care. Community paramedics do not have the training to assess adverse health effects of medication interactions as their training in pharmacology is extremely limited.

FISCAL COMMENTS

According to the Assembly Appropriation Committee, EMSA will require one specialist for the EMS Systems Division and an analyst for the EMS Personnel Division. The staff would promulgate regulations, establish uniform standards for implementation and oversight of community paramedicine programs, meet with stakeholders, facilitate an advisory committee, perform site visits to field programs, and approve local community paramedicine plans.

EMSA also reports the EMS and EMSA Systems and Personnel unit data collection processes might have to be altered as the community paramedicine program matures. EMSA would request funds for software and data standards revisions.

EMSA estimates total costs of $443,000 in fiscal year (FY) 2023-24 and $383,000 in FY 2024-25 and annually through FY 2030-31 (General Fund).

VOTES

ASM HEALTH: 15-0-0

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner Horvath, Wendy Carrillo, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

UPDATED

VERSION: February 13, 2023

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0000539

Date of Hearing: May 3, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 767

Author:(Gipson) – As Introduced Ver:February 13, 2023

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

SUMMARY:

This bill adds short-term, post discharge follow-up for persons recently discharged from a hospital to the list of eligible services in a community paramedicine program. This bill also extends the sunset date of the community paramedicine program from January 1, 2024, to January 1, 2031.

FISCAL EFFECT:

The Emergency Medical Services Authority (EMSA) will require one specialist for the Emergency Medical Services (EMS) Systems Division and an analyst for the EMS Personnel Division. The staff would promulgate regulations, establish uniform standards for implementation and oversight of community paramedicine programs, meet with stakeholders, facilitate an advisory committee, perform site visits to field programs, and approve local community paramedicine plans.

EMSA also reports the EMS and EMSA Systems and Personnel unit data collection processes might have to be altered as the community paramedicine program matures. EMSA would request funds for software and data standards revisions.

EMSA estimates total costs of $443,000 in fiscal year (FY) 2023-24 and $383,000 in FY 2024-25 and annually through FY 2030-31 (General Fund).

COMMENTS:

1. Purpose. According to the author:

Today's existing healthcare model of directing all transports to hospitals has created congestion in Emergency Departments. Community Paramedicine can play an important role in improving California's health care delivery system and is an innovative model of care. This program seeks to improve the effectiveness and efficiency of health care delivery by using specially trained paramedics in partnership with other health care providers to address the needs of local health care systems. The pilot program started by AB 1544 (Gipson, 2019) has been extremely successful but, due to a lengthy development process the community paramedicine and triage to alternate destination regulations did not take effect until November 1, 2022. Therefore an extension of the sunset is needed for the programs to be fully established and given a fair chance.

1. Background. AB 1544 (Gipson), Chapter 138, Statutes of 2020, enacts the Community Paramedicine or Triage to Alternate Destination Act of 2019, which permits local EMS agencies (LEMSAs), with approval by EMSA, to develop programs to provide community paramedic or triage to alternate destination services in one of the following specialties: (a) providing directly observed tuberculosis therapy; (b) providing case management services to frequent emergency medical services users; (c) providing hospice services to treat patients in their homes; and, (d) 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.
2. Prior Legislation.
   1. AB 820 (Gipson), of the 2017-18 Legislative Session, would have allowed a LEMSA to transport specified patients to a community care facility, as defined, in lieu of a hospital. AB 820 was held in Assembly Health Committee.
      
   2. AB 1650 (Maienschein), of the 2017-18 Legislative Session, would have created the Community Paramedicine Program (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. AB 1650 was held on the suspense file in this committee.
   3. AB 1795 (Gipson), of the 2017-18 Legislative Session, would have authorized 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. AB 1795 also would have authorized a city, county, or city and county to designate, and contract with, a sobering center to receive patients and established sobering center standards. AB 1795 would have required EMSA to adopt guidelines for the triage criteria and assessment procedures and to annually analyze administration of local plans and issue a report, as specified. AB 1795 was held on the suspense file in this committee.
   4. AB 3115 (Gipson), of the 2017-18 Legislative Session, was similar to AB 1544. AB 3115 was vetoed by Governor Brown, who stated in part:

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

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

• 1. SB 944 (Hertzberg), of the 2017-18 Legislative Session, was substantially similar to AB 1544. SB 944 was held on the suspense file in this committee.

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

Date of Hearing: April 11, 2023

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 767

Author:(Gipson) – As Introduced Ver:February 13, 2023

SUBJECT: Community Paramedicine or Triage to Alternate Destination Act.

SUMMARY: 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. Specifically, this bill:

1. Adds providing short-term, postdischarge follow-up for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible, to the list of community paramedicine services.
   
2. Requires EMSA, on or before January 1, 2025, to amend regulations adopted pursuant to existing law to include the program specialty described in 1).
3. Deletes the requirement that a community paramedicine short-term, post-discharge followup pilot program that was approved on or before January 1, 2019, under the Office of Statewide Health Planning and Development’s (OSHPD, now the Department of Health Care Access and Information [HCAI]) Health Workforce Pilot Project No. 173, and was continuing to enroll patients as of January 1, 2019, may continue operation until January 1, 2024.
   
4. Extends the effective date of the provisions described above from January 1, 2024, to January 1, 2031.

EXISTING LAW:

1. Establishes 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. [Health and Safety Code (HSC) §1797.100, et seq.]
2. Authorizes counties to develop an EMS program and designate a LEMSA (LEMSA) 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 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 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 LEMSA 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 Department of Health Care Access and Information (HCAI), formerly 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 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]
    
11. Establishes the Community Paramedicine or Triage to Alternate Destination Act of 2020, and states the intent of the Legislature that, among other provisions, delivery of community paramedicine or triage to alternate destination services is a public good and is complementary to the existing emergency response system. [HSC §1800]
    
12. Defines “community paramedicine program,” as a program developed by a LEMSA and approved by EMSA to provide community paramedicine services consisting of one or more of the following the program specialties under the direction of medical protocols developed by the LEMSA that are consistent with the minimum protocols established by EMSA. Permits community paramedic services to consist of the following specialties:
    1. Providing directly observed therapy to persons with tuberculosis in collaboration with a public health agency; and,
    2. Providing case management services to frequent EMS users in collaboration with, and by providing referral to, existing appropriate community resources. [HSC §1815]
13. Defines “triage to alternate destination program,” as a program developed by a LEMSA and approved by EMSA to provide triage paramedic assessments consisting of one or more of the following specialties operating under triage and assessment protocols developed by the LEMSA that are consistent with the minimum triage and assessment protocols established by EMSA:
    1. Providing care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient’s and family’s immediate care needs, including grief support, in collaboration with the patient’s hospice agency until the hospice nurse arrives to treat the patient;
    2. Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility; and,
    3. Providing transport services for patients who identify as veterans and desire transport to a local veterans administration emergency department (ED) when appropriate. [HSC §1819]
       
14. Prohibits anything in the “triage to alternate destination program” from preventing or eliminating any authority to provide continuous transport of a patient to a participating hospital for priority evaluation by a physician, nurse practitioner, or physician assistant before transport to an alternate destination facility. [Id.]
15. Prohibits anything in the “triage to alternate destination program” from impairing or otherwise interfering with an EMS provider’s ability to deliver emergency medical transport services as authorized under a provision of law permitting exclusive operating areas in a local EMS plan, or a city or fire district to operate under provisions of law allowing cities and fire districts to continue providing services at the same level as they were provided prior to June 1, 1980. [Id.]
16. Defines the following terms:
    1. “Alternate destination facility” is a treatment location that is an authorized mental health facility, as defined, or an authorized sobering center;
    2. “Authorized mental health facility” is a facility that is licensed or certified as a mental health treatment facility or a hospital, including a certified crisis stabilization unit, and including a psychiatric health facility licensed by the Department of Health Care Services (DHCS), and requires the facility to be staffed at all times with at least a registered nurse;
    3. “Authorized sobering center” is a facility that is a noncorrectional facility that is staffed at all times with at least one registered nurse, and is either a federally qualified health center, a facility certified by DHCS to provide nonresidential detoxification services, or a facility that has been accredited as a sobering center under standards developed by the National Sobering Collaborative;
    4. “Community paramedic” is a licensed paramedic who has completed the curriculum for community paramedicine as described, has received certification in one or more of the community paramedicine program specialties described in this bill, and is accredited to provide community paramedic services by a LEMSA 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 LEMSA;
    6. “Public agency” is a city, county, special district, or other political subdivision of the state that provides first response services, including emergency medical care;
    7. “Triage Paramedic” is a licensed paramedic who has completed the curriculum for triage paramedic services under this bill, has been accredited by a LEMSA in one or more of the triage paramedic specialties described in this bill; and,
    8. “Triage to alternate destination provider” is an advanced life support provider authorized by a LEMSA to provide advanced life support triage paramedic assessments as part of an approved triage to alternate destination program specialty. [HSC§1811-1820]
17. 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]
    

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

COMMENTS:

1. PURPOSE OF THIS BILL. According the author, today's existing healthcare model of directing all transports to hospitals has created congestion in EDs. Community Paramedicine can play an important role in improving California's health care delivery system and is an innovative model of care. The author notes that this program seeks to improve the effectiveness and efficiency of health care delivery by using specially trained paramedics in partnership with other health care providers to address the needs of local health care systems. The pilot program started by AB 1544 (Gipson), Chapter 138, Statutes of 2020, has been extremely successful but, due to a lengthy development process the community paramedicine and triage to alternate destination regulations did not take effect until November 1, 2022. The author concludes that an extension of the sunset is needed for the programs to be fully established and given a fair chance.
2. BACKGROUND. AB 1544, enacts the Community Paramedicine or Triage to Alternate Destination Act of 2019, 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: a) providing directly observed tuberculosis therapy; b) providing case management services to frequent emergency medical services users; c) providing hospice services to treat patients in their homes; and, d) 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.
   1. Background on HWPP #173. In November of 2014, HCAI, then OSHPD, 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 ensuing years, including a seventh concept testing transporting patients to a sobering center. The following are the concepts 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.

Since its initial approval for the original one-year period, HWPP #173 has been renewed five times. The last renewal was codified under AB 1544, and unless renewed again, it is scheduled to end on December 30, 2023.

• 1. Update of Evaluation of California’s Community Paramedicine Pilot Program. The HWPP regulations require organizations that sponsor pilot projects to retain an independent evaluator to assess trainee performance, patient acceptance, and cost-effectiveness. The Philip R. Lee Institute for Health Policy Studies and Healthforce Center at UC San Francisco conducted the most recent evaluation, released February 18 2021, which was funded by the California Health Care Foundation. Key findings are as follows:
     1. Status of Pilot Projects. Thirteen pilot projects were launched from June through October of 2015. Seven more projects began enrolling patients in 2017, 2018, and 2019. Five projects have closed, and one has suspended operations. Two Post-Discharge – Short-Term Follow-Up projects closed due to lack of local resources and one has suspended operations. The three Alternate Destination – Urgent Care projects closed due to low enrollment. The pilot projects enrolled 10,855 persons through September 30, 2020. An update of six of the seven programs is below. This analysis does not discuss the Alternate Destination – Urgent Care pilot because none of those pilots are currently in operation.
        1. Post-Discharge Short-term follow-up. From June 2015 through September 2020, the five Post-Discharge – Short-Term Follow-Up projects have enrolled 1,814 patients. Butte’s project had the largest enrollment (1,001 patients), and Alameda’s had the smallest (140 patients). The Post-Discharge – Short-Term Follow-Up projects have improved patient safety by performing home visits within a few days of a patient’s hospital discharge to ensure that patients understand their discharge instructions, are taking medications as prescribed, have sufficient refills to manage their conditions, have follow-up visits scheduled with their physicians and are adhering to any dietary restrictions pertinent to the management of their condition. Through September 2020, the five Post-Discharge – Short-Term Follow-Up projects avoided potential costs of approximately $1.4 million, the majority of which (61%) would accrue to Medicare.
        2. Frequent EMS User. The three Frequent EMS User projects have enrolled 481 people from July 2015 through September 2020 and have achieved large reductions in the number of 911 calls made on behalf of their clients and the number of transports to EDs. Frequent EMS User projects have linked patients to organizations that provide primary care, dental care, mental health services, substance abuse treatment, food, housing, transportation, and other services that can address their needs more effectively than the EMS system.
           
        3. Directly Observed Therapy for Tuberculosis (TB). The TB project enrolled 52 persons from June 2015 through September 2020. Most patients

are enrolled for multiple months because treatment for TB typically spans six to nine months. Community paramedics dispensed appropriate doses of TB medications, and their TB patients did not experience side effects any more frequently than typically associated with TB treatment. Twelve patients were admitted to a hospital in the period during which the project has been in operation, but only one patient was hospitalized for TB. This patient needed intravenous medication to treat TB meningitis, which had been diagnosed prior to enrollment in the program. People with TB who received directly observed treatment (DOT) from community paramedics were more likely to receive all doses of TB medications prescribed by the TB clinic physician than people who received DOT from the TB clinic’s staff.

• • • 1. Hospice. The Hospice project enrolled 422 persons between August 2015 and September 2020 and reduced the likelihood that patients who preferred treatment at home were transported to an ED, which could result in loss of hospice benefits. No patients were denied transport to an ED when it was indicated and consistent with the patient’s preference. Among hospice patients enrolled in the pilot project, the percentage of 911 calls that resulted in transport to an ED decreased from 80% to 28%. The Hospice project avoided potential costs of $318,097 by reducing ambulance transports and ED visits.
         
      2. Alternate Destination – Mental Health. The four Alternate Destination – Mental Health projects enrolled 5,093 persons between September 2015 and September 2020. Across the four projects, 27% to 44% of patients screened were transported to the mental health crisis center rather than an ED. In Stanislaus County, an additional 29% could have been transported to the crisis center if the county had more inpatient psychiatric beds or if the crisis center accepted people with private insurance or Medicare. 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 can help reduce ED overcrowding.
         
      3. Alternate Destination – Sobering Center. The three Alternate Destination – Sobering Center projects enrolled 2,945 persons from February 2017 through September 2020. Four hundred and twelve patients (14%) were treated at the sobering center more than once. Most patients (2,849) were enrolled in San Francisco’s Alternate Destination – Sobering Center project. Los Angeles’ project has enrolled 96 people since it launched in late June of 2019. The Santa Clara County EMS Agency and the Gilroy Fire Department’s Alternate Destination – Sobering Center project has not enrolled any patients as of September 2020. 98.2% of patients enrolled in San Francisco’s Alternate Destination – Sobering Center project were treated safely and effectively at the sobering center. Only 51 patients (1.7%) were transferred to an ED within six hours of admission to the sobering center, and only two (0.1%) were rerouted from the sobering center to an ED because registered nurses at the sobering center declined to accept them. Only five patients were admitted to a hospital for inpatient medical care.
         
  1. Paramedic training. 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 LEMSA. A core curriculum was developed that HCAI 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.
     
  2. 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.

1. SUPPORT. The California Professional Firefighters (CPF), a sponsor of this bill, state that community paramedicine programs as implemented first under pilot programs throughout the state and then fully authorized by AB 1544 have shown considerable positive impacts in the communities where they operate. These programs empower trained paramedics to provide additional, much needed services to their communities, reducing the strain on EDs and facilitating improved access to services such as mental health crisis centers and targeted interventions for frequent EMS users. When communities are asked who they trust, firefighters are always ranked among the most trustworthy leaders, making them well-positioned to utilize existing resources and apply expanded protocols developed by medical and behavioral health experts to improve patient care throughout the jurisdictions they serve. Further, firefighters are positioned throughout the community 24/7 at strategically placed firehouses. As such, community paramedicine programs will allow for timely and improved access to essential services.
   
   The California Chapter of the American College of Emergency Physicians (California ACEP) also a sponsor of this bill states that, in 2020, AB 1544 was signed into law to expand EMT scope of practice to authorize several of the concepts tested in the pilots including transporting patients to sobering centers and mental health facilities rather than EDs. That law will sunset on December 31, 2023 unless legislation is passed this year to extend the sunset. There are several innovative community paramedicine programs currently being operated in cities throughout the state providing improved care to frequent 911 utilizers, hospice patients, and patients who would benefit from the continuation of these programs. California ACEP notes that they are pleased to co-sponsor this bill to extend the sunset on this scope expansion while maintaining some statewide standards and important patient safety protections.
   
2. OPPOSITION. The California Association for Health Services at Home (CAHSAH), opposes this bill and states that it is an expansion of the scope of paramedics into licensed home care, home health and hospice services by individuals who are neither trained, licensed, nor regulated to provide such services. This bill gives broad authority to local EMS authorities to create standards for treating vulnerable patients in the home by individuals who do not have the training and expertise to care for the specific needs of these patients. Home care, home health and hospice agencies are explicitly regulated under California law, with home health and hospice services further regulated under the Medicare Conditions of Participation to ensure patient safety is not jeopardized. This bill will allow paramedics to provide home care, home health and hospice services without having to meet the same licensure, regulatory or personnel training requirements as licensed home care, home health and hospice agencies. CAHSAH notes that training and scope of practice are the major differences between paramedics and nurses. Nurses complete a nursing diploma program including an associate or bachelor’s degree in nursing, which takes two to four years to complete. Although paramedics and nurses perform some of the same tasks, such as starting an intravenous line, nurses have an extremely broad scope of practice that includes emergency, acute, convalescent and outpatient care, while paramedics are limited to pre-hospital emergency care. Community paramedics do not have the training to assess adverse health effects of medication interactions as their training in pharmacology is extremely limited.
   
3. CONCERNS. The California Nurses Association (CNA) has submitted a letter of concern regarding this bill. CNA is concerned that the expansion of post-discharge follow-ups as a form of EMS would erode the scope of nursing practice and result in delays in patients receiving nursing care through home health programs. CNA states that it is unclear how EMS personnel would be able to assess when nursing care is required for patients and communicate the need for nursing care to providers. Hospitals may also take advantage of the expansion of post-discharge programs by shifting nursing care and wound care away from home health registered nurses to EMS personnel who provide post-discharge services. EMS personnel would be asked to make assessments on when acute or home health nursing care is necessary, but this nursing care assessment should always be performed by registered nurses. CNA contends that even the most well-intentioned EMS personnel would not be able to assess a patient’s nursing care requirements of patients and would not know when nurses should be altered to intervene.
   
4. RELATED LEGISLATION.
   1. AB 40 (Rodriguez) requires EMSA to develop a public education campaign related to the use of the 911 service, and to develop a system requirement for an electronic signature for use between the ED and an EMT 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). Requires EMSA to develop a statewide standard of 20 minutes, 90% of the time for APOT. Requires a general acute care hospital (GACH) with an ED, by June 1, 2024, to develop an APOT reduction protocol, that addresses specified factors. Requires EMSA, on or after March 1, 2024, to monitor APOT for each facility that is required to report. AB 40 is pending in the Assembly Health Committee.
   2. AB 379 (Rodriguez) requires a LEMSA to adopt policies and procedures for calculating and reporting APOT. Requires a LEMSA to develop and submit an EMS system plan to the EMSA and requires the LEMSA to annually submit its emergency medical services plan for the EMS area to EMSA. Require LEMSAs and EMSA to make the plans accessible on the LEMSA’s and EMSA’s internet websites within 30 days of approval by EMSA. AB 379 is pending in the Assembly Committee on Emergency Management.
   3. AB 1164 (Lowenthal) requires a licensed GACH with an ED to determine the range of crowding scores that constitute each category of the crowding scale, as provided, for its ED. Requires the hospital to calculate and record a crowding score at a minimum every four hours, except as specified, to assess the crowding condition of the hospital’s ED. Requires, by January 1, 2025, the hospital to develop and implement a full-capacity protocol for each of the categories of the crowding scale, and requires the hospital to file its protocol with HCAI and to annually report any revisions to its protocol. AB 1165 is pending in the Assembly Health Committee.
5. PREVIOUS LEGISLATION.
   1. AB 1544 enacts the Community Paramedicine or Triage to Alternate Destination Act of 2019, which permits local emergency medical services agencies, with approval by the Emergency Medical Services Authority, to develop programs to provide community paramedic or triage to alternate destination services in one of the following specialties: 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. The provisions of this bill sunset on January 1, 2024.
   2. AB 3115 (Gipson) of 2018 was similar to AB 1544. AB 3115 was vetoed by Governor Brown, who stated in part, “Though the health workforce pilot project started in 2014, local community paramedicine programs are using paramedics to assist in the transportation and care of patients in settings other than an emergency room. While this bill has the good intention of making the pilot project permanent, it restricts the types of facilities to which patients can be transported. It also limits the discretion of local governments to design and manage their projects in the way they think best.
      
      I support these innovative local efforts and believe they should be expanded but without the restrictions contained in this bill. To achieve that, I am directing the continuation of the existing pilot project and encouraging all of the interested parties to work together to make this program permanent.”
   3. AB 1795 (Gipson) of 2018 would have authorized 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. Would have authorized a city, county, or city and county to designate, and contract with, a sobering center to receive patients, and established sobering center standards. AB 1795 would have required EMSA to adopt guidelines for the triage criteria and assessment procedures by July 1, 2020, and 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. SB 944 (Hertzberg) of 2018 was substantially similar to AB 1544. SB 944 was held on the Assembly Appropriations Committee suspense file.
   5. 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 hospital. AB 820 was held in the Assembly Health Committee.
      
   6. AB 1650 (Maienschein) of 2017 would have created the Community Paramedicine Program (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.

REGISTERED SUPPORT / OPPOSITION:

Support

California Chapter of the American College of Emergency Physicians (cosponsor)

California Professional Firefighters (cosponsor)
California Medical Association

Emergency Nurses Association, California State Council
LeadingAge California

Opposition

California Association for Health Services at Home

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