Assembly Standing Committee on Emergency Management

All right. Good afternoon. Want to welcome everybody to Emergency Management Committee. I'm Assembly Member Freddie Rodriguez, chair of the emergency management. Welcome to today's hearing. Let's turn to today's agenda and remind everyone of the ground rules for today's hearing. As always, we seek to protect the rights of all who participate in the legislative process so that we can have effective deliberations and decisions on the critical issues facing California. In order to facilitate these goals, we will not permit conduct that disrupts, disturbs or otherwise impedes the orderly conduct of the legislative proceedings. At today's hearing, we'll take public comments from those in the room. Members of the public may also submit testimony to the Committee at AEM.assembly.ca.gov. First, let's establish a quorum. Committee Secretary, can you please take the role?

[roll call]

Having established a quorum, our next order business is the consent calendar. The following bills are on consent, AB 296 Rodriguez. The motion is do passed to the Committee of Communications and Conveyance. AB 781 Maienschein. The motion is do pass to the Committee on Appropriations. AB 813 Rodriguez. The motion is do passed to the Committee on Appropriations. Do I have a motion? A second to approve items on the consent. The motion is motioned by Alvarez, second by Dahle. Secretary, please call the roll on the motion to approve the consent calendar.

On the consent calendar, AB 296 Rodriguez, motion is do pass to Committee on Communications and Conveyance. AB 781 Maienschein, the motion is do pass to Committee on Appropriations on consent. AB 813. Rodriguez, motion is do passed to Committee on Appropriations on consent. [Roll Cal]

Consent Calendar's up. We leave the roll open for any members. So with that, I'll wait one more minute, see if Assembly Member Fong shows up. If not, I'll go ahead and present on my bill. Before we go to that, let's go ahead and open up the role on the consent calendar. Secretary, call the missing members. Are we all here?

We're doing AB 40. Mr. Rodriguez, you can begin when you're ready.

Thank you chair and members. I'm pleased to present AB 40 this afternoon, which will require the Emergency Medical Service authority to adopt emergency regulations to prevent the long offload delays to ensure ambulances are available to respond to 911 calls for emergency medical services. As someone who spent over 32 years working as a first responder in the emergency medical services system, I am all too familiar with wall times. In fact, I've personally waited for over 12 hours at a hospital to transfer a patient. Wall times are bad for patient care. Wall times are bad for the EMTs and paramedics and all first responders, and for nurses and physicians. Excessive wall times has been a problem for decades. Wall times occur when an ambulance arrives at a hospital and is forced to wait for the hospital to assume responsibility of care for the patient. Not only do wall times result an ultimately care untimely care for patients experiencing emergency, but it prevents first responders and paramedics from responding to other emergencies. Last year, this committee held an oversight hearing all times. A representative from the Sacramento Fire Department testified about an incident where a fire department paramedic was performing CPR on a patient with two ambulances at a hospital around the corner waiting to transfer patient care for more than an hour. The fire department ultimately needed an ambulance from a neighboring jurisdiction to respond from 8 miles away and three cities over because other resource weren't available. The ambulance sent to the scene was the 20th pick in terms of distance, but was the closest available resource. This is unacceptable. EMSA convened a wall time task force in November 2021. In June of 2020, the EMSA Walltime Task Force voted on 19 recommendations to mitigate ambulance patient offload delays. This bill will codify some of the most important impacts, such as a public education campaign for proper use of 911 and developing a statewide standard of 20 minutes 90% of the time for ambulance patient offload times. With that, let me turn it over to my witnesses in support, Captain Sean Burroughs, Alameda County Fire Department and President of the Alameda Firefighters and battalion chief Matt Cole, Sacramento Fire or Metropolitan Fire Department, and Vice President of the Sacramento Firefighters.

Good afternoon, members of the committee. My name is Sean Burrows, I'm a 27 year veteran of the fire service and serve as a fire captain and paramedic for the Alameda County Fire Department. And I also serve as President of the Alameda County Firefighters Local 55. Ambulance patient offload time, or wall time, continues to grow, and firefighters throughout the state are being pushed to the brink. From a firefighter perspective, there are two measurable and critical impacts to patient care and public safety that I am experiencing and I know is being experienced across the state. First, paramedics are stuck on the wall at hospital emergency departments. Not only is this delaying a patient from getting care at the hospital, but takes critical 911 resources out of the field. Second, there is a downstream impact for our firefighter paramedics.

Fire engines are consistently waiting on scene for an ambulance to ride because zero ambulances are available in our system. Recently, an Alameda County fire engine waited on scene with a patient for nearly 90 minutes because there were no available ambulances. Not only is the patient impacted by not receiving timely emergency services, the fire engine is unable to respond to any additional incidents in our response area. These delays are not oneoffs or anomalies, they occur daily and throughout the state.

AB 40 will direct the EMS authority to enhance data collection, establish a statewide standard, and will hire hospitals to develop protocols to reduce wall times if they exceed a statewide standard. Reducing wall times directly benefits the patient and our residents. Would you want your loved one to be waiting for hours at the emergency Department after being transported by an ambulance? Or could you imagine experiencing a medical emergency and having to wait for an ambulance to arrive because all resources are tied up on the wall? No Californian should have to experience a delay in emergency medical care, and for these reasons, we respectfully ask for your support for AB 40. Thank you.

Good afternoon, Members of the Committee. My name is Matt Cole and I also am a 27 year veteran of the fire service and currently serve as a battalion chief for the Sacramento Metropolitan Fire District and Vice President of the Sacramento Area Firefighters Local 522. The fire service has worked for years to try to drive solutions to help alleviate ambulance patient offload time, including measures to enhance data collection and community paramedicine.

As a battalion chief in the Sacramento area, I have seven transporting units that are assigned to my battalion and unfortunately, more times than I can count, I have had zero available. Not only does this cause our first responders to remain on an emergency scene with no way to help a person get to the hospital, but it also means that those same first responders are not available to answer the next call for help.

Numerous times I have shown up at hospitals to feed crews that have been on the wall for hours or to try to encourage some sort of movement to get rigs back into the system, only to find that there are empty beds that our patients could be moved to. You can imagine how frustrating this must be for me when my sole charter is to ensure my crews are out there answering the calls for help. My frustration, however, is not with the nurses or doctors. They are our partners in caring for the community. Their job is clinical care and ours is prehospital care. But when the management teams of these hospitals refuse to provide enough equipment or staff, our taxpayers end up supplementing these private hospitals with public safety personnel that should be providing prehospital care. This bill is an important step to ensure that there is hospital accountability. We do our job of equipping and staffing our firefighters to triage, treat and then transport our patients to the hospital.

It's the hospital's turn to ensure that they are equipped to do theirs. Your constituents fund our services and they expect their emergency response system, the entire system, to be efficient and effective. Firefighters serving as de facto staff of an emergency department while a patient is waiting for care is not an effective or efficient system. And we need to work to address this issue. For all these reasons, we respectfully request your support of AB 40. Thank you.

Thank you. Are there other witnesses in support? Name? Organization position only, please.

Thank you. Madam Vice Chair and members, Doug Zubers, on behalf of the California Professional Firefighters, in strong support.

Good afternoon, chair Members. Janice O'Malley, American Federation of State County Municipal Employees. Here representing local 4911. Our EMT, paramedics, nurses and dispatchers in support of AB 40. Thank you.

Madam Chair Members. Nick Romo, on behalf of the League of California Cities, in support.

Thank you. We'll call for witnesses in opposition to come forward, please.

Latifah Alexander, with the Association of California Healthcare districts. We're not opposed, but we do have concerns with the bill and we look forward to working with the author's office. Thank you.

I've been emergency department RN for 19 years, have been in the ED leadership for 12 years. There is no greater priority for me and my emergency department than the safety of our patients.

And while we agree that APOC delays are a problem and support many of the provisions in AB 40, Sutter Health and more than 20 of our emergency departments are opposed to AB 40 unless it is amended to remove the statewide 20 minutes ambulance patient offload time and make it more of a collaborative approach to reducing offload delays.

There's a lack of access to primary and specialty care, resulting in an increase of 13% patient volume for Sutter Roosevelt in 2022. For example, 45 of our 68 beds have patients awaiting transferred to their next level of care, leaving us 23 beds to see 300 new patients expected to arrive at the door.

If we cannot get patients out the back door makes it difficult to get patients in the front door. Last year alone, we hired 143 additional staff in the ED.

We expanded our department from 38 to 68 beds in 2020 still, we cannot keep up with the unprecedented volume growth. If we truly want to reduce delays, it will take a collaborative approach between hospitals, fire, ambulance, LEMSAS and others to get to the root cause of these delays.

Simply setting a 20 minutes standard without addressing the systemic changes that are causing delays will not solve the problem.

As an example of working collaboratively, Senator Roosevelt worked with our LEMSAS San Ramon Valley Fire and ambulance for many months to reduce offload delays by creating an APOC committee.

This took intense work to review the data and hold both hospital and EMS providers accountable by reporting discrepancies in real time for follow up with the agencies. Even with all this work, we're still at 32 minutes in the 90th percentile.

Committee members, it is also important to understand that there has been no study or analysis on why 20 minutes will be the statewide standard. Every part of the state is so different. What works for a rural county will not work for urban areas of the state like Los Angeles or even Sacramento.

A one size fits all approach for the entire state is just not appropriate. It's also important to note the data being reported to MSA to track APOC times is unreliable.

When hospitals conduct our own audits, we find discrepancies such as differing transfer of care times up to 90 minutes and even APOC recorded times for patients that were never transported to our hospital.

It is critical importance that hospitals have the opportunity to validate the data because data drives change. Before we can even look at setting a statewide standard, we must have accurate data, to track offload times. Thank you.

Good afternoon, Madam Chair and members. Betsy Armstrong with the County Health Executives Association. But here today on behalf of the EMS Administrators Association of California, EMSAAC is not opposed to the bill.

However, they do have some concerns with several provisions of the bill. APOC is a complex issue and involves many stakeholders, including hospitals, EMS providers, regulatory agencies such as LEMSAS, the EMS authority and CDPH, among others.

EMSAAC appreciates the author's efforts to address this problem, but any solution must include all stakeholders to address the multiple factors we outlined in our letter causing extended waits for EMS personnel and emergency departments.

Furthermore, we would like to note that counties are already required to create medical surge plans through their hospital preparedness programs, so we are unclear on how the requirement in AB 40 differs from existing planning practices.

We commit to continuing to work with the Chair and his staff, and we appreciate you listening to our concerns. Thank you.

Thank you. Other persons in opposition name organization position.

Chairwoman and other members, Paul Yoder, on behalf of the Solano County Board of Supervisors. They are opposed to the bill, and they urge your no vote.

Good afternoon. Vanessa Gonzalez with the California Hospital Association and we would align our comments with those of Ms. Colangelo's from said her health we are opposed to AB 40 unless it is amended to remove the statewide 20 minutes standard and takes a more collaborative approach to addressing the systemic challenges that our emergency or EMS system face. Thank you.

Sumaya Nahar, on behalf of the MemorialCare health systems, we also have an opposed unless amended position on the bill. Thank you.

Good afternoon, Madam Chair and committee members. Jonathan Clay and Baffa Scripps Health also opposed unless amended.

Good afternoon, Madam Chair and members. Connie Delgado, on behalf of the 5000 emergency nurses in the California Emergency Nurses Association, with an opposed unless amended position.

Good afternoon. Megan Loper, on behalf of the United Hospital Association, also with an opposed unless amended position.

Alison Raimi, on behalf of Kaiser Permanente, also with an opposed unless amended position.

Thank you. Seeing no other persons in opposition, I'll bring them back to the committee for questions. Comments? Yes.

Thank you, Madam Chair, I have a question, I guess for opposition. Are there different thresholds you believe are more achievable than the 20 minutes, 90% of the time threshold in the bill?

Thank you for that question. So we do feel that leaving it to the LEMSAS to work collaboratively with their local hospitals is a better opportunity for them to work on a number that we could be more successful at.

So, for example, where we are at set of Roseville in Placer County, they have a 20 minute right now because that was what. Sorry. When the book came out in 2014, CHA and EMS worked together on a toolkit, and they had a 15 to 30 minute.

But that book was from 2014. And what we recommend is that we look at that toolkit and see how we can revisit it from 10 years ago to see how it would be more applicable to today.

But looking at those times, too, we work super hard and have done a lot of collaborative work with Sutter, Roseville, with placer county, with SSB, to look at those times. And we are challenged at hitting that 20 minutes, even doing that piece of it.

But each LEMSA, in collaboration and working together, I feel, can achieve that number. That would be a successful number for them to achieve.

Okay, thank you. Ms. Aguria Curry.

Sure. Thank you, Assembly Member, for bringing this bill forward. And you know that I always am scared and worried about my rural communities, right. And so the one size fits all doesn't always work. However, it's only fair that we sit down and have more mitigation on this bill.

I think it's important public safety issues addressed, has multiple contributing players. I'm going to support your bill today because I know that you will work hard in trying to figure this out. I just don't want to be left behind.

And you've heard that a million times from me. So I'll vote for your bill today but expect to see some changes before it hits the floor. Thank you very much.

Mr. Alvarez.

Thank you, Ms. Waldron. First of all, thank you to the chair for the bill. And I want to thank the advocates on both sides for first, I should acknowledge that coming from neither the hospital setting or from the emergency management systems, I am being educated on what this bill is attempting to do.

And I think what really kind of stands out to me is that even though there's two sides to this discussion, everybody wants to get to the same thing.

So it makes it even more complicated. And that's certainly the intent of our chair, which is to provide better quality care for people. And that's really what it should always be about.

And I want to acknowledge that. I have two questions that are kind of basic and really for anybody to answer, feels comfortable answering. One is on the 20 minutes standard. Just curious. And maybe there's two different positions on our views on this. Is there a different standard in other states?

Is there a standard in the industry? I'm just curious, how does this compare to other standards? And again, both sides. Yeah.

Thank you. Assemblymember Doug Subers. On behalf of the California Professional Firefighters, there are different standards within the state and different local EMS agencies.

There are several local EMS agencies that have indicated a 20 minute standard, as well as the State Emergency Medical Services authority that the assemblymember referenced in his opening but do recognize that there are other LEMASS that have 25 minutes and 30 minutes standards.

I think from the CPS perspective, our members often have to be on scene in less than 8 minutes and to arrive to provide prehospital care for someone who calls 911. And so from that perspective, we think 20 minutes is an appropriate balance and it does have 20 minutes, 90% of the time to allow some flexibility for situations in which it does go over.

Okay, thank you.

And I think to your question too, looking at other states and doing some research on it, there isn't really a standard across different states. Across our state we do have that variation, but we can look at our emergency Department for the ambulance fade for entire arrival till they get to the triage nurse is 7 minutes.

So that gives our staff 13 minutes to try to get the patient checked in, make sure that they can verify what kind of bed that patient is going to need on arrival and then get them to that bed and turnover of care to our nurse in that framework.

And so that's why looking at working with the different lenses independently at the different systems sites would work to make that accommodation.

Let me just make sure I understand that correctly. So you're sharing with us that there's a standard of 13 minutes once there's an arrival at a hospital to evaluate and make a decision.

I'm sorry. So once they arrive into the parking lot in our ambulance bed, using our facility as an example, so once they arrive, that's the arrival time. So once they offload the patient and bring the patient in to get to the registration area, it could take them 7 minutes.

So when you have an offload time of 20 minutes total, that gives the hospital 13 minutes to try to register that patient and then find an appropriate bed to place them in.

Are there standards based on triage in terms of acuity of care that are either national standards or not or existing standards?

Yes. And thank you for bringing that forward also. So we have in the emergency departments, we use a triage tool to identify patients when they're coming in, and it's called the ESI, the emergency severity index.

And so that way we can triage patients either versus walking in or coming in by ambulance and decide what level that patient's at to determine who needs that appropriate care first. And so, we follow that same triage regardless whether somebody comes in by ambulance or walks in the department.

So we can triage them to the most appropriate area and triage them safely to make sure that they're seen in a timely fashion.

To the issue of the 20 minutes, what is the penalty, if you will? I don't think I identified any, and maybe to the proponents part of this bill. What is the penalty if someone doesn't meet that standard on a regular basis or whatever the 90% of the time is the standard. Is there any penalty associated with that?

Well, I think the way the measure is constructed, if the acute care hospital with an emergency department exceeds the standard, they would have to implement the protocol that is required in section three of the bill.

Certainly, and then if that protocol, if there was an exceedance of the 20 minutes standard, 90% of the time for a month, then the EMSA would notify that hospital and there would be steps.

And just to speak to collaboration, it would direct the MSA to host weekly calls with the relevant hospital administration, EMS providers, local EMS agency hospital employees to discuss implementation of the protocol.

I think the goal, from our perspective, is to drive reductions in these ambulance patient offload times to make sure our members are back into the field and providing that prehospital care. So that's the mechanism that's in the bill currently that would happen if a hospital were to exceed their 20 minutes standard.

So, are you saying that it's not your expectation that this bill would require the 20 minutes, you'd monitor it, and if it's in excess of 20 minutes, then you go into a process of improvement? Basically.

Yes. I mean, it establishes a statewide standard. That is the standard that the expectation is that the hospitals would meet that transfer of care. But if they do not meet that standard, the way the bill is constructed, it would require the hospital to initiate that protocol, which they have to complete upfront.

So the bill would require them to complete the protocol, but it would be required to be implemented if they exceeded that timeline for a month or more.

What would you expect that to look like then, really? Because what we're hearing from hospitals is a lot of them aren't meeting the 20 minutes. I mean, just to be very realistic. So what would you expect their plan to do that would change that and get us to under 20 minutes, 90% of the time.

Yeah. I think from our perspective, there are places where hospitals can make investments to efficiently expedite the transfer of care. They could have triage teams on site at the hospital to meet ambulance crews when they come in the door to triage that patient and accept patient care.

In the absence of some action by the hospital, our members and firefighters are often waiting to transfer that patient care and often providing care and comfort services, as you heard the witnesses testify, for sometimes several hours, and that patient is not getting care.

Follow up on that. But what is your perspective on the bill in either one of you, about what the language says about if the 20 minutes standard isn't met and what you'd be required to do?

I think that that's being very reactive to a problem that we need to be proactive about. And so having the collaboration, having the APOC committees with our LEMSAS, having things in place to address some of those, we reduced our times from an hour and 40 minutes to 32 minutes.

And that was with collaboration, that wasn't happening. So we brought that collaboration to the table, and we're doing the same thing with Sacramento County right now, across our site.

So in our 20 sites across Sutter, across the Bay and the Valley, we're working together.

We created a system wide APOC Committee, and so we're working together to share best practices on what's working at some sites and what's not working at other sites, and how can we help each other share those best practices to improve, which is very proactive.

And then collaborating and bringing our LEMSAS together with our fire and EMS agencies to make sure we're doing real time data exchange. We struggle at the hospital level to try to get that data, and data really drives change.

If we could get the data and collaborate with the LEMSAS at looking at those times, instead of being reactive, we could be proactive. And then when we have a surge, we all have surge plans. You heard our counties have surge plans.

But when we have a surge, then it's reacting to a number of patients coming in at once. But we should be focusing on being very proactive and looking at some of these other opportunities that we can work on together, collaboratively to try.

Are you stating that you believe there's a way to reduce even further your wait times, which you've already said went from well over an hour to 30 something minutes to closer to 20 minutes?

I think that's in the data collection. I think that we don't have a good tool to measure the arrival and the transfer of care time, which we're working on across our sites for our 20.

And then not only just working internally with Sutter, but working across different healthcare systems across the states to look at what they're using and what's working and not working. And how then they can look at their LEMSAS to get that data to make sure that we're looking and comparing apples to apples, oranges to oranges.

So that way, like I said, data drives change. And having that data up front, I can look at yesterday's data and say, okay, these were the barriers.

We have a system in place at our site and we've shared it with across our system that we're trying to implement is when we get an ambulance call. If our MICN, our mobile intensive crisis nurse that can't have a bed plan for that patient, either triage or a room if needed at 20 minutes, they escalate to our charge nurse who if they can't place that patient, it escalates all the way to me. We barely hit an hour.

Now, last month we had 11 ambulances that were there greater than an hour. And then when we pulled those 11, eight of them, two of them didn't even come to our facility.

But that APOC time was on our report and the other six of them that came were patients that would never have waited because they were either traumas or CPRs and they were APOC times of 90 minutes, which didn't happen. And so it's hard to drive change when we don't have that data in real time, and we can't get it till we request it.

Okay, I understand data is an issue. Last two questions are related to potentially items that can process changes that could maybe create efficiencies.

Scripps Health, which is one of the providers in San Diego, wrote that, as an example, when an ambulance brings a patient to one of the emergency rooms, that has low acuity, so the person in the ambulance has low acuity and does not require supervision, which happens often, we quickly check that patient into our waiting room.

Sharp, also in San Diego, wrote that 20% of arrivals into Sharp's emergency department, 55% are lower acuity. I don't know whether Sharp does the waiting room or not, but is this a tactic or something that is more common or less common?

The idea of reviewing acuity and placing them potentially in a waiting room as opposed to in the emergency room on a bed.

So fortunately, I actually came from Scripps. So I was down there. I was in Southern California also, as I have the statewide perspective. So many of our facilities, that is one of that best practices that we're looking at across the state to make sure that we're all doing it, we should all be doing it the same, but again, making sure that we're standardized those best practices across the state to make sure that every facility is doing it is absolutely something that we want as a state to look at.

How can we create an APOC Committee, not just at our local levels, but at the state to do that exact thing? Sacramento actually introduced policy to ensure that that was happening across Sacramento, and we're working on that still and still developing that piece of it because there's some changes we need, but absolutely that should be happening.

All right, I'll end with that. I'll just recognize that the work that the Chair is trying to do is trying to do exactly that, which is to reduce wait times. And given that there's still apparently some practices that are not standardized in hospitals, it's worthwhile for that discussion alone if there are good practices, best practices.

I would hope that as this bill moves forward, we can maybe adopt some of those as part of this conversation and certainly data collection to be able to be more proactive as opposed to reactive as I still am getting more informed with this topic and wanting to see some of those practices potentially be discussed as part of this moving forward.

I'm going to abstain from voting today, but I want to recognize the work, particularly the Chair is doing in this regard and hope that we can continue conversation so that I can support this at the next stop. Thank you.

So this isn't new to anybody. We're living in 2023 now and we still have not solved this issue other than want more time, more data or we don't even want a time at all, period. Because let us figure it out.

Are there any other comments, questions? Ms. Doll.

I just want to kind of elaborate from my own personal experiences as we talk about more data in this issue regarding APOC times and the fact that I've been trying to work with all the stakeholders, probably the last three years, and the fact that this isn't a new issue that maybe just came about because of the pandemic.

This has been going on for decades. I could tell you over 20 years ago, I personally waited for 12 hours in an emergency room.

I don't think anybody here other than the firefighters back there can tell us what that means. Standing against a wall for 12 hours, waiting for a bed because the facility I went to didn't maybe have appropriate staffing or the beds waiting for a number of things.

That means it's not going to get done. If they haven't done it 20 years ago, what insurances are going to be in place that's going to get done in 30 days, six months, a year? There really isn't any incentive. In the meantime, we're getting our first responders stuck in a wall, we having delayed 911 response times.

And not to mention, I don't think the firefighters talked about it, but I think maybe they have.

What do we do when our first responders show up on scene of a medical emergency and there's no ambulance available? Because part of the reason is they're stuck at a hospital. And what's the worst result? They're going to put that patient in back of a fire engine and transport to a hospital or worst case, a police car.

And I'm saying police car because not too long ago, my son is a police officer down Southern California, and he told me, dad, on a call they went to, no ambulance were available. They had to throw a patient in the backseat of a police car to drive code three to a hospital because no ambulance were available. And once again, this has been going on for decades.

Is this still the things we're going to have to be responsible out there when people are suffering and dying and folks in the hospitals are going to say we need more time. All due respect to our hospital folks, our doctors, our nurses, our technicians, they do a great job.

But I think now we need to do something more concrete to make sure all our patients are getting their fair treatment and care, whether it's emergency or non-emergency, and really get our first responders back out there to provide service to those critical patients.

And it's going to take some time. But like I said, I've been asking for a time, asking for some additional language to address the issue for over three years now.

And going back to, once again, I hate to say it, over two decades, waiting 12 hours in a hospital waiting room is totally unacceptable. That was half my shift because I work 24 hours shifts. So I just wanted to lay that out there. And I know somebody had some other questions.

I think more of just a comment. I think Aguiar-Curry and I both have the same lens, which is our rural hospitals, and they're currently in opposition. And I think what I'm hearing from them is staffing shortages. We don't have even ER doctors that are traveling. And that's a real issue for us. And so I also wanted to have a little more clarity about the triaging. Right.

If people are walking into an ER and then I'm concerned that if an ambulance shows up, you're going to prioritize the ambulance for the fear of penalty. I understand that.

Thank you for the questions that there is not currently a penalty in this bill, but our rural hospitals are on, and I'm just speaking about our small rural hospitals. They are on a financial cusp. They really are.

And so I think just the fear of penalty is also where is driving part of a big part of their opposition. And for me personally, I want to make sure that our patients aren't, and I am not in the medical field. I've learned a lot through this whole process.

But if you walk in and you're having a heart attack, but someone shows up with a sprained ankle, I want to make sure that in that the patient and the ambulance gets priority because of fear of penalty.

So can maybe you just talk a little bit more about the triage because I don't understand that piece. Thank you.

No, and thank you for bringing that forward. So on a daily basis, on average, we have 300 patients that walk in or we have 300 patients that we'll see, 70 of those are by ambulance. We prioritize all patients regardless whether we are being fined or not.

I'm a member of a community, too, and I want 911 to be available for my family members also. But being in the emergency department, we make sure that we're doing the right thing for the patient.

And that's why it's so important for us to work together and collaboratively because we all have the same goal. We're all here to advocate for our patients and to be a resource for our community. I don't want ambulances sitting in a hospital for 12 hours. I don't want them sitting in there for more than 30 minutes. I want to get them out.

I want to get them out safely for the patients and make sure that those patients that chose not to call 911, because sometimes it is those patients that are a little bit more stubborn and might drive themselves in because they've waited and didn't want to call 911 are getting that priority, too.

So absolutely, regardless what happens, we will always do what's right for the patient, which I think is what we're all saying and why this is all so important to us and why we're so passionate about it.

Thank you. And I'll just say a comment myself. We all agree it's unacceptable the way it is right now with patients waiting sometimes hours, certainly over 40 minutes up to 90, as well as paramedics standing on the wall affecting public safety and then not able to get out there and help other people and respond to calls.

So this is a critical issue. It's been mentioned San Diego County has a 30 minutes ambulance patient offload time that they're working with, but one size doesn't fit all.

Hospitals are different, situations are different. Having the LEMSAS have more local control is also important because they know what's going on in the local area. I'm supportive of this bill today, and I want to be able to see more interaction and more work on some of these issues.

And we'll see it a couple of times in the assembly for sure. So, my hope is that some of these critical issues can be worked out because it is an important issue. We need to deal with it. Mr. Chair, would you like to close?

With that said, I respectfully ask for aye vote. Thank you.

Is there a motion? We have a motion in a second.

We do have do pass to Health Committee, is the motion. Madam Secretary, please call a roll.

[Roll Call]

On AB 40. The motion is do pass to Committee on Health.

All right, before we go to the next Bill, somebody, Member Fong, just want to make that motion. That Bill is out with five votes. Okay. That Bill is out. Okay, next we have. Where we at? Okay, see Mr. Funk, please present AB 619. When you're ready, sir. Go ahead.

Thank you, Mr. Chair Members. California nonprofits are deeply engaged in our communities, and as you all know, that, and provide essential services both independently and through government contracted projects. When a State of emergency is declared, nonprofits who contract with the state do not have the flexibility needed to pivot to handle the crisis and continue to deliver critical community based services. This Bill will afford nonprofits who have state contracts, the ability to modify programs and program budgets to flexibly respond to immediate needs.

As seen by the prolific response from nonprofits over the last couple of years, they assist the state's boots on the ground response to emergency situations. Unfortunately, their contractual budget restrictions with the state often limit their ability to adequately adapt to fit the needs of an unpredictable situation. Contract modifications can take many months. Nonprofits need to be able to act flexibly to respond appropriately and quickly in an emergency.

Many times, these emergencies cannot be predicted nor prepared for, and the response requires adaptation from the state and their contracted partners to deftly service the communities they are responsible for. As seen at the beginning of the pandemic, emergencies often required immediate changes to contracted programs. Resources were bottlenecked and nonprofits did not have the ability to reprioritize their state funds to provide the much needed services to their communities.

With the recent flooding emergencies affecting communities across the state, but especially in my community in the Central Valley, these proposed contract modifications will allow for resources to be better utilized to help the people who are in desperate need of additional flood assistance. Greater contract flexibility will allow these nonprofits to successfully implement and engage our communities during crisis responses for future emergencies relating to health, wildfires, or other natural disasters. I'm joined today by Jennifer Fury on behalf of the California Association of Nonprofits in Support.

Thank you. Go ahead.

Thank you. Good afternoon, Mr. Chair and Members. I am Jennifer Fearing, the Sacramento Advocate for California Association of nonprofits or Cal nonprofits, and we are very pleased to support AB 619 to bring much needed contract flexibility during state emergencies to nonprofits providing direct services under contracts with California State agencies. For those of you who don't know us, Cal Nonprofits is the statewide policy alliance of more than 10,000 organizations serving as the voice for California's nonprofit community.

I am also pleased to convey support today on behalf of my other nonprofit clients, the San Diego Humane Society and Meals on Wheels California AB 619 is part of the California nonprofit Equity initiative that we, along with more than 550 nonprofit and community leaders, called for in an October 2022 letter to Governor Newsom and legislative leaders.

The combination of impacts from the pandemic, higher economic insecurity and inflation, and what feels like near constant natural disasters of one type or another are increasing demands for our services and have pushed the partnership between California State government and nonprofits to a critical juncture. It's challenging our mutual efforts to deliver the highest quality service to the people of California, especially in our most vulnerable communities.

We provide vital services, including 32% of all medical services, and nonprofits stepped up even more during the pandemic to respond quickly and flexibly to the needs of Californians during 2020. We surveyed more than 600 nonprofits from across 48 counties and found that 86% needed changes in their state contract deliverable requirements as a result of the pandemic's impact on their work.

For example, a nonprofit foster care agency was unclear how to contend with performance obligations when shelter in place requirements complicated required home visits to confirm the health and safety of foster care children. A nonprofit mental health provider for Medi Cal recipients wanted to adjust its payments to ensure providers would not have to be laid off and needed quick agency guidance in order to make those changes.

And California's nonprofit senior nutrition providers had to quickly pivot to congregate meals from the congregate meals they usually provided to home delivered meals for tens of thousands of vulnerable seniors, and we needed the confidence that they would be reimbursed. AB 619 would provide, in a declared emergencies, that nonprofits party to a contract with the state may adjust their contract to accomplish the primary purpose of the contract.

Importantly, the Bill will require nonprofits to notify the contracting agency of any changes to services and expenses, and again, and as soon as their contracting agencies are able, through triage, which I heard mentioned during the last Bill, get to these nonprofits to declare what they'd like to see done. We are asking that nonprofits be trusted in the interim to deliver services and maintain what we know our communities need from us during those moments.

So your Committee unanimously supported Senator Glazer's very similar effort last session, and we thank you, assemblymember Fong, for continuing the effort and respectfully request an I vote.

Thank you. There's a motion and second, I think, a motion by Calderon, second by Aguilar. Curry. Is there anyone else in support? I think we have somebody coming up.

Chair and Members Austin Webster with W Strategies on behalf of 211 Orange County. In support.

Anyone else in support? Seeing none. Anyone in opposition to AB 619? Seeing none. With that, we're bringing back to Committee Members. Any questions, comments? Seeing none. With that. Assembly Member Fong, any closing?

I respectfully ask when I vote.

Thank you. The motion do pass, Committee appropriations will be supporting it as well. Thank you, Secretary Calderon.

Okay, AB 619, the motion is do passed to Committee and appropriations.

[Roll Call]

That motion is out. Thank you.

Thank you.

So with that, this meeting is adjourned. Thank you.

Thank you. Yeah.

Sounds good. You. Know. Yeah. Thanks, folks. Good closing, by the way. Yeah. Walter, sorry about that. First time working with you up here, but however you prefer those notes.