SUBJECT
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REIMAGINING AMBULANCE TRANSPORTATION SERVICES IN THE COUNTY’S RURAL COMMUNITIES (DISTRICTS: ALL)
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OVERVIEW
On December 5, 2017 (5), the Board of Supervisors approved a revised ambulance transportation model in the County’s unincorporated communities known as the Unified Service Area (USA). The programmatic changes consolidated the three (3) Exclusive Operating Areas and seven (7) undesignated or non-exclusive operating areas where the County has the responsibility to ensure ambulance services, into one service area wherein a provider(s) could be contracted. The County contracted with one private ambulance vendor to provide at least ten (10) paramedic, Advanced Life Support (ALS) ambulances and one part-time ALS ambulance. Despite the enhancements that came with unifying and expanding service, the remote location of communities, low transport revenue, and paramedic staffing challenges still hinder the viability of the current ambulance transportation model.
On October 4, 2021, the State of California enacted Assembly Bill (AB) 389 which included provisions for a county Board of Supervisors to contract with a fire agency for ambulance services and for the fire agency to subcontract service, in whole or in part, to a private provider, as codified into California Health and Safety Code (HSC) Sections 1797.230-231. On December 13, 2022 (1), the Board directed the Chief Administrative Officer to hire a consultant to evaluate the optimal ambulance transportation service model(s) within the USA given the statutory change, along with, as of January 1, 2023, increased Medi-Cal payments to government-provided ambulance services. San Diego County Fire completed a competitive procurement for a consultant and contracted with Citygate Associates, LLC (Citygate) to conduct the review. Citygate was tasked with evaluating fiscal sustainability, patient care, and operational objectives of a future ambulance services model. To leverage the best combination of service options and revenues newly available, and to ensure the County meets the emergency medical services needs of vulnerable communities, Citygate is recommending that San Diego County Fire Protection District (SDCFPD) assume responsibility as the ambulance service manager/provider for the USA when the current private ambulance services contract in the USA ends.
The actions in today’s Board Letter and accompanying SDCFPD Board of Directors agenda item provide the authority to subcontract, as needed, for private ambulance services and/or in combination add firefighter/paramedic ambulance staffing. The final service model to be implemented will meet the standards established by the Board on December 13, 2022 (1). Today’s action authorizes a contract between the County of San Diego and the SDCFPD to manage and/or provide emergency, non-emergency, interfacility, and special event/standby ambulance services in the areas where the County provides those services, or may in the future, consistent with California and Federal authorities and new California HSC Sections 1797.230-231. The contract between County and SDCFPD will be effective upon the expiration of the existing ambulance services contract in the USA.
RECOMMENDATION(S)
CHIEF ADMINISTRATIVE OFFICER
1. Authorize the Chief Administrative Officer or designee, on behalf of the County of San Diego, to enter into a contract with the San Diego County Fire Protection District (SDCFPD) to exclusively provide and/or manage emergency ambulance services in the areas where the County has, or will have, the responsibility for ambulance transportation services in compliance with California Health and Safety Code Sections 1797.230-231 and approve any amendments to the contract. SDCFPD may provide ambulance services, in whole or in part, through a written subcontract with a private ambulance service, in compliance with Health and Safety Code Section 1797.231.
EQUITY IMPACT STATEMENT
Advanced (paramedic) and Basic (Emergency Medical Technician) Life Support ambulances are a critical component of an emergency medical services system reducing emergency medical health disparities in the USA’s unincorporated areas. San Diego County Fire will continue working with Citygate Associates, LLC to review Emergency Medical Services incident data to determine how staffing patterns and ambulance deployment models will provide for equitable services across the Unified Service Area. County Fire will track data and outcomes for quality of timely care by race, gender, and geography to support positive outcomes for all residents.
SUSTAINABILITY IMPACT STATEMENT
Implementing the new ambulance transportation model provides for a just and equitable access to County resources. This action also supports efforts for our services to reflect the County’s values and priorities.
FISCAL IMPACT
There is no fiscal impact associated with today’s recommendations in the current fiscal year. Fiscal impacts will be determined when staff evaluates the final report from Citygate and staffing options and will return to the Board for consideration and approval of recommendations.
BUSINESS IMPACT STATEMENT
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Details
ADVISORY BOARD STATEMENT
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BACKGROUND
The San Diego County Emergency Medical Services (EMS) Office, a division of San Diego County Fire, is the Board of Supervisors-designated Local EMS Agency (LEMSA). Acting in that role, the EMS Office oversees the region’s emergency medical system. Part of those duties include countywide responsibility for procuring ambulance contracts in previously designated Exclusive Operating Areas (EOA), both incorporated and unincorporated, for medical and quality assurance oversight of the EMS system and improving health and patient outcomes for everyone. On December 5, 2017 (5), the Board of Supervisors (Board) approved the creation of the Unified Service Area (USA). Prior to this action, the EMS Office oversaw three (3) EOAs and seven (7) non-exclusive or undesignated operating areas which resulted in disparate service levels to rural communities. With the establishment of the USA, operational and financial efficiencies supported additional advanced life support ambulances to the most rural communities, resulting in more equitable service levels for unincorporated area residents.
On October 4, 2021, the State of California enacted Assembly Bill (AB) 389 and added Health and Safety Code Sections 1797.230-231. This statute authorizes a county Board of Supervisors to contract with a fire agency to manage and/or provide emergency ambulance services and includes certain requirements for fire agencies that elect to subcontract, in whole or in part, for private ambulance transportation services that provides protections for private ambulance personnel. On December 13, 2022 (1), the Board directed the Chief Administrative Officer (CAO) to hire a consultant to evaluate ambulance service and cost options within the USA to improve the provision of services. The goal is to ensure a model that reduces health disparities, improves patient care in rural communities, and potentially increases the presence of firefighter/paramedics in some of our most rural, hard to serve, and vulnerable population areas.
On February 9, 2023, after a competitive procurement process, the County contracted with Citygate Associates, LLC (Citygate) to conduct this analysis. Citygate will support County staff with reviewing data and recommending a service model that meets the requirements established by the Board on December 13, 2022 (1). County staff is working with Citygate to finalize a design for an emergency medical system in the Unified Service Area that is equitable and sustainable. In evaluating fiscal sustainability, patient care, and operational objectives in a future ambulance services model, Citygate is recommending that the San Diego County Fire Protection District (SDCFPD) assume responsibility as the ambulance service manager/provider for the USA. The LEMSA will maintain its statutorily required role to provide medical and quality control over all SDCFPD ambulance services to promote care and well-being.
Contracting with the SDCFPD supports several County objectives. By placing the provision of ambulance transportation services under the direct control of the County’s fire agency, rather than through the use of a contractor, staffing patterns and deployment models are first determined by call volume and patient needs for transportation to definitive care, at times over long distances, to county hospitals In addition, firefighter/paramedics on ambulances in rural communities bolsters staffing capacity to respond to all hazard emergencies such as structural and wildland fires. Firefighter/paramedics can perform more duties than private personnel in response to such emergencies. Lastly, a subcontracted private provider could have additional abilities to support the County efforts to redirect lower-acuity patients to community-based alternatives for healthcare such as nurse navigation or strengthening future Community Paramedicine initiatives.
The contract between the County and SDCFPD will become effective upon the expiration of the existing ambulance services contract in the USA.
If the Board approves the actions in today’s Board Letter, there is an accompanying item on the SDCFPD Board of Directors agenda to provide County staff with the authority to subcontract for a private ambulance operator to support firefighter/paramedics in the County’s agreement with CAL FIRE. The final service model to be implemented will meet the standards established by the Board on December 13, 2022 (1). Today’s action authorizes the CAO, on behalf of the County, to enter a contract with the SDCFPD to provide and/or manage emergency, non-emergency, interfacility, and special event/standby ambulance services in the areas where the County provides those services, or may in the future, consistent with HSC Sections 1797.230-231.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s proposed actions support the Equity and Community Initiatives of the County of San Diego’s 2023-2028 Strategic Plan. The proposed ambulance transportation model will support its regional programs that are reducing health disparities in our rural communities and ensuring all residents have access to life saving emergency medical services that promote patient care and well-being.
Respectfully submitted,
HELEN N. ROBBINS-MEYER
Interim Chief Administrative Officer
ATTACHMENT(S)
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