SUBJECT
Title
COMMUNITY PARAMEDICINE, COMMUNITY HEALTH AND INJURY PREVENTION, AND TRIAGE TO ALTERNATE DESTINATION PROGRAM UPDATE (DISTRICTS: ALL)
Body
OVERVIEW
On May 4, 2021 (3), the Board of Supervisors directed the Chief Administrative Officer to explore establishing a Community Risk Reduction medical services program within San Diego County Fire. This program would focus on proactive service delivery within the San Diego County Fire Protection District (SDCFPD), which includes many rural communities experiencing significant health disparities.
On November 2, 2021 (1), County Fire, in collaboration with Health and Human Services Agency (HHSA), proposed a three-phase approach to meeting the Board’s direction. The first phase includes the SDCFPD, through its partnership with CAL FIRE, establishing a Community Health and Injury Prevention (CHIP) initiative to offer training such as Hands-Only CPR, Stop the Bleed, and other wellness initiatives to District residents. Phase 2 includes local implementation of Assembly Bill (AB) 1544, the Community Paramedicine and Triage to Alternate Destination (CP/TAD) Act. Local implementation of these programs could not begin until the State finalized regulations, which occurred November 1, 2022. The third phase includes addressing long-term public health needs in SDCFPD that County Fire and HHSA jointly support.
Today’s request is for the Board of Supervisors to receive an update on the local implementation of CP/TAD programs and County Fire’s CHIP initiative.
RECOMMENDATION(S)
CHIEF ADMINISTRATIVE OFFICER
1. Receive an update on the development of the County Fire Community Health and Injury Prevention initiative and the County Emergency Medical Services Office’s local implementation of Community Paramedicine and Triage to Alternate Destination programs.
EQUITY IMPACT STATEMENT
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 with statutory responsibilities for the county’s EMS delivery system, including quality assurance/quality improvement and structural innovation. Community Paramedicine and Triage to Alternate Destination (CP/TAD) programs aim to improve equitable healthcare access, particularly for those struggling with behavioral health and addiction. CP/TAD programs will connect participating Fire/EMS services with other County programs, like Crisis Stabilization Units, sobering centers, and other health and social support programs.
More than 80 percent of the San Diego County Fire Protection District’s (SDCFPD) jurisdictional area qualifies as a disadvantaged unincorporated community, based on a San Diego Local Agency Formation Commission report on the funding, administration, and performance of the SDCFPD. County Fire continues to engage communities in developing a community health initiative to improve residents’ health and quality of life within the SDCFPD’s jurisdictional area.
SUSTAINABILITY IMPACT STATEMENT
The proposed action to receive the Community Paramedicine, Community Health and Injury Prevention, and Triage to Alternate Destination program updates contribute to the County of San Diego’s Sustainability Goals to protect the health and well-being of the county’s residents and visitors by providing additional tools to the Emergency Management Services (EMS) delivery system. County residents and visitors will be better able to access tailored healthcare resources through these innovative EMS programs. These capabilities improve the health and well-being of all San Diego County residents and visitors.
FISCAL IMPACT
There is no fiscal impact associated with today’s recommendations in the current fiscal year. There may be fiscal impact related to any future decisions by the Board to implement Community Paramedicine, Community Health and Injury Prevention, and Triage to Alternate Destination programs in San Diego County Fire Protection District. San Diego County Fire will return to the Board of Supervisors to request approval of any future actions with a fiscal impact and identify funding at that time. There will be no change in net General Fund cost and no additional staff years in the current Fiscal Year.
BUSINESS IMPACT STATEMENT
N/A
Details
ADVISORY BOARD STATEMENT
Beginning in 2020, the Emergency Medical Care Committee has received regular progress updates on Community Paramedicine, Community Health and Injury Prevention, and Triage to Alternate Destination (CP/TAD) development and has supported CP/TAD program implementation. The Fire Services Advisory Board endorsed the Community Health and Injury Prevention initiative at its October 2021 meeting and subsequently has received regular updates.
BACKGROUND
Community paramedicine is an innovative and evolving model of Emergency Medical Services (EMS)-based healthcare designed to provide more effective and efficient services at a lower cost. Community paramedicine allows paramedics to help facilitate tailored health and emergency resources while enhancing access to primary care for medically underserved populations. On May 4, 2021 (3), the Board of Supervisors directed the Chief Administrative Officer to explore the feasibility of establishing a medical services program within San Diego County Fire and to return to the Board to provide updates. On November 2, 2021 (1), County Fire returned to the Board and proposed a three-step program to meet the Board’s direction.
Phase 1: Community Health and Injury Prevention Initiative
Through County Fire’s partnership with CAL FIRE, the SDCFPD has a growing EMS presence of firefighter/paramedics in rural communities. Since November 2021, County Fire has provided:
• 89 Stop the Bleed, EpiPen®, naloxone, and Hands-Only CPR and AED training courses
• 64,076 COVID-19 and 3,470 influenza immunizations
• 93,168 COVID-19 viral test swab collections
The authority for paramedics to provide COVID-19 and Influenza vaccinations and testing ended on February 28, 2023, when the Governor’s executive order expired.
Phase 2: Community Paramedicine and Triage to Alternate Destinations (CP/TAD)
On November 1, 2022, the California Emergency Medical Services Authority (EMSA) announced CP/TAD regulations took effect and are ready for local implementation. The County EMS Office, as the local EMS agency (LEMSA), accelerated ongoing local program development for our region’s Fire/EMS service providers to implement their own programs. The final CP regulations authorized:
• Supporting public health and tuberculosis patients with directly observed therapy
• Providing case management services to frequent 9-1-1 system users by connecting vulnerable individuals with services best able to address their social and medical needs.
The TAD regulations expanded the 9-1-1 system by enabling:
• Additional methods for supporting hospice patients and their families without transportation to an emergency department
• Paramedic ambulance transport through set criteria to specific alternate destinations:
o Behavioral health facilities, like Crisis Stabilization Units
o Sobering centers
o Veteran’s Administration hospital emergency rooms
Local Implementation Efforts
The County EMS Office, as the LEMSA, is authorized by AB 1544 and EMSA regulations to develop voluntary, local CP/TAD guidelines. These guidelines will come in the form of CP/TAD plans, policies, and protocols. The EMS Office has convened a stakeholder Advisory Council to help guide this effort. This Council includes key stakeholder representatives from fire, emergency medical services, and medical communities.
After finalizing numerous policies and protocols, anticipated to be completed by July 2023, the EMS Office will seek EMSA approval. Following state review and approval, local agencies may request LEMSA authorization for implementation; under statute, the LEMSA is responsible for reviewing and authorizing all CP/TAD programs countywide. In addition, the EMS Office is taking the following actions:
• Seeking partnerships with potential alternate destination sites. To be an eligible alternate destination site, participating mental health and sobering facilities must have a Registered Nurse on site around-the-clock.
• Working with community partners, such as the City of San Diego, to develop standards for the county’s first Community Paramedic training program.
• Facilitating the adoption of the City of San Diego’s long-standing CP pilot program as a LEMSA-approved CP/TAD program, as required by statute.
• Determine if fees are needed for EMS Office CP/TAD services.
• Identifying any available CP/TAD or other EMS program innovation grants to support program funding.
While these steps to full implementation are well underway, County Fire believes CP/TAD programs could do more to bolster health care options and reduce health disparities if legislation allowed for paramedics to:
• administer vaccines, as the prior pandemic emergency authorizations have ended,
• provide post-hospital discharge follow-up care without a nurse needing to be present to reach rural and isolated residents,
• provide transportation options to urgent care versus solely to emergency departments.
County Fire will continue to identify legislative opportunities through the Board's legislation program.
Phase 3: Emerging Patient Care Models
County Fire continues to implement the third phase of the Board’s approved plan. On March 14, 2023 (6), the Board authorized a post-hospital discharge follow-up pilot program in the Mountain Empire community to reduce hospital readmissions. County Fire and HHSA will directly address health disparities in this innovative model. This initiative represents a meaningful change in how the County supports the health and wellness in the geographically expansive backcountry. As this program progresses, staff will continue to identify opportunities for further HHSA/County Fire cooperative approaches in the third phase of this plan.
Since the onset of the COVID-19 pandemic, the region’s EMS and healthcare system has experienced a significant increase in the need for patient care. When patients call 9-1-1, paramedics are limited to transporting patients to an emergency department, with narrow expansions through new TAD programs. Rigid statutory language limits the options to match individual patient needs with the most appropriate level of care. County Fire will continue exploring medically appropriate practices and fiscal sustainability, including:
• Expanding HHSA, County Fire, and health system partnerships, like the discharge follow-up pilot program in the Mountain Empire community
• Practitioner/paramedic response units to treat low-level medical needs in the community rather than a hospital when appropriate. This reduces wait times at hospitals, and can be medically appropriate and more cost-effective for the patient
• Telehealth visits
Together, today’s actions will support County Fire, County EMS, and HHSA initiatives and equip staff with additional tools to provide innovative and tailored healthcare throughout the county.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s proposed action is to receive an update on the development of the County Fire Community Health and Injury Prevention (CHIP) initiative and the County EMS Office’s local implementation of Community Paramedicine and Triage to Alternate Destination programs to provide additional direction to the CAO for further program development. This action supports the Equity & Community initiatives of the 2023-2028 Strategic Plan by addressing the provision of robust, equitable, and accessible emergency medical services throughout the region.
Respectfully submitted,
HELEN N. ROBBINS-MEYER
Interim Chief Administrative Officer
ATTACHMENT(S)
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