Amended  IN  Senate  March 21, 2018

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Senate Bill No. 944

Introduced by Senator Hertzberg

January 29, 2018

An act to amend Section 1797.272 of, and to add Chapter 13 (commencing with Section 1800) to Division 2.5 of, the Health and Safety Code, relating to community paramedicine.


LEGISLATIVE COUNSEL'S DIGEST


SB 944, as amended, Hertzberg. Community paramedicine programs: guidelines. Community Paramedicine Act of 2018.
(1) Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, governs local emergency medical services (EMS) systems. The act establishes the Emergency Medical Services Authority, which is responsible for the coordination and integration of emergency medical services. Among other duties, the authority is required to develop planning and implementation guidelines for emergency medical services systems, provide technical assistance to existing agencies, counties, and cities for the purpose of developing the components of emergency medical services systems, and receive plans for the implementation of emergency medical services and trauma care systems from local EMS agencies. A violation of the act or regulations adopted pursuant to the act is punishable as a misdemeanor.
This bill would create the Community Paramedicine Act of 2018. The bill would authorize a local EMS agency to develop a community paramedicine program, as defined, to provide specified community paramedic services. The bill would require the authority to review a local EMS agency’s proposed community paramedicine program and approve, approve with conditions, or deny the proposed program within 6 months after it is submitted by the local EMS agency. The bill would require a local EMS agency that opts to develop a community paramedicine program to, among other things, integrate the proposed program into the local EMS agency’s emergency medical services plan, enter into an agreement with a community paramedicine provider for the delivery of community paramedic services within the local EMS agency’s jurisdiction that is consistent with the proposed program, establish a process for training and certifying community paramedics, and facilitate and participate in any discussion between a community paramedicine provider and public or private health system participants to provide funding to support implementation of the proposed program.
The bill would create the Community Paramedicine Oversight Committee to advise the authority on, and approve minimum medical protocols for, community paramedicine program specialties. The bill would require the authority to develop, in consultation with the committee, regulations that establish minimum standards for the development of a community paramedicine program. The bill would require the authority to submit an annual report on the community paramedicine programs operating in California to the relevant policy committees of the Legislature beginning 6 months after the authority adopts the regulations and every January 1 thereafter for the next 5 years.
The bill would prohibit a person or organization from providing community paramedic services or representing, advertising, or otherwise implying that it is authorized to provide community paramedic services unless it is expressly authorized by a local EMS agency to provide those services as part of a community paramedicine program approved by the authority. The bill would also prohibit a community paramedic from providing community paramedic services if he or she has not been certified to perform those services and is working as an employee of an authorized community paramedicine provider. Because a violation of the act described above is punishable as a misdemeanor, and this bill would create new requirements within the act, the violation of which would be a crime, the bill would impose a state-mandated local program.
(2) Existing law authorizes a county to establish an emergency medical care committee and requires the committee, at least annually, to review the operations of ambulance services operating within the county, emergency medical care offered within the county, and first aid practices in the county. Existing law requires the county board of supervisors to prescribe the membership, and appoint the members, of the committee.
This bill would require the committee to include additional members, as specified, and to advise a local EMS agency within the county on the development of its community paramedicine program if the local EMS agency develops a community paramedicine program.
(3) 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 act establishes the Emergency Medical Services Authority, which is responsible for the coordination and integration of emergency medical services. Among other duties, the authority is required to develop planning and implementation guidelines for emergency medical services systems, provide technical assistance to existing agencies, counties, and cities for the purpose of developing the components of emergency medical services systems, and receive plans for the implementation of emergency medical services and trauma care systems from local EMS agencies.

This bill would declare the intent of the Legislature to enact legislation that establishes statewide guidelines for, and authorizes the implementation of, community paramedicine programs in California, as specified.

Vote: MAJORITY   Appropriation: NO   Fiscal Committee: NOYES   Local Program: NOYES  

The people of the State of California do enact as follows:


SECTION 1.

 Section 1797.272 of the Health and Safety Code is amended to read:

1797.272.
 (a) The county board of supervisors shall prescribe the membership, and appoint the members, of the emergency medical care committee. If two or more adjacent counties establish a single committee, the county boards of supervisors shall jointly prescribe the membership, and appoint the members of the committee.
(b) If a local EMS agency within the county develops a community paramedicine program pursuant to Section 1840, the emergency medical care committee shall also include the following members and shall advise the local EMS agency on the development of the community paramedicine program:
(1) Two emergency room physicians practicing at an emergency department within the local EMS agency’s jurisdiction.
(2) Two registered nurses practicing within the local EMS agency’s jurisdiction.
(3) Two emergency medical technician-paramedics practicing in the local EMS agency’s jurisdiction. At least one of the emergency medical technician-paramedics shall be employed by a public agency.
(4) The medical director for the local EMS agency.
(5) One acute care hospital representative with an emergency department operating within the local EMS agency jurisdiction.

SEC. 2.

 Chapter 13 (commencing with Section 1800) is added to Division 2.5 of the Health and Safety Code, to read:
CHAPTER  13. Community Paramedicine
Article  1. General Provisions

1800.
 This chapter shall be known, and may be cited, as the Community Paramedicine Act of 2018.

1801.
 (a) It is the intent of the Legislature to establish state guidelines that govern the implementation of community paramedicine programs by local EMS agencies in California.
(b) It is the intent of the Legislature that a community paramedicine program developed by a local EMS agency be submitted to the Emergency Medical Services Authority for review and approval.
(c) It is the intent of the Legislature to improve the health of individuals in their communities by authorizing emergency medical technician paramedics, working under expert medical oversight, to deliver community paramedicine in California utilizing existing providers, promoting continuity of care, and maximizing existing efficiencies within the first response and emergency medical services system.
(d) It is the intent of the Legislature that a community paramedicine program developed by a local EMS agency and authorized by the Emergency Medical Services Authority will do all of the following:
(1) Improve coordination among providers of medical services, behavioral health services, and social services.
(2) Reduce preventable ambulance transports, emergency department visits, and hospital readmissions.
(3) Preserve, protect, and deliver the highest level of patient care to every Californian.
(e) It is the intent of the Legislature that an alternate destination facility participating as part of an approved community paramedicine program will always be staffed by a higher medical authority, such as, at minimum, a registered nurse, if ensuring transfer of a patient from a community paramedic to the higher medical authority is in the best interests of the patient.
(f) It is the intent of the Legislature that the delivery of community paramedic services is a public good to be delivered in a manner that promotes continuity of care and continuity of providers and is consistent with, coordinated with, and complementary to, the existing first response and emergency medical response system in place in a local EMS agency’s jurisdiction.
(g) It is the intent of the Legislature that a community paramedicine program be designed to improve community health and be implemented in a fashion that is respectful of the current emergency medical system and its providers. Whenever possible, and in furtherance of the public interest and public good, public agencies that provide first response services should deliver care under a community paramedicine program. In most circumstances, public agency providers are first on scene in a medical emergency.
(h)  It is the intent of the Legislature that the development of any community paramedicine program reflects input from all practitioners of appropriate medical authorities, including, but not limited to, medical directors, physicians, nurses, mental health professionals, first responder paramedics, hospitals, and other entities within the emergency medical response system.
(i) It is the intent of the Legislature that local EMS agencies be authorized to develop a community paramedicine program to improve patient care and community health. A community paramedicine program should not be used solely to reduce personnel costs, harm working conditions of emergency medical and health care workers, or otherwise compromise the emergency medical response or health care system in a way that is focused primarily on containing costs. The highest priority of any community paramedicine program should be improving patient care and providing further efficiencies in the emergency medical system.

Article  2. Definitions

1810.
 Unless otherwise indicated in this chapter, the definitions contained in this article shall govern the provisions of this chapter.

1811.
 “Alternate destination facility” means a treatment location that is an authorized mental health facility or an authorized sobering center, but not a general acute care hospital, as defined in subdivision (a) of Section 1250.

1812.
 “Authorized mental health facility” means a facility that is a licensed psychiatric hospital, a licensed psychiatric health facility, or a certified crisis stabilization unit, and has at least one registered nurse staffed onsite at the facility at all times.

1813.
 “Authorized sobering center” means a facility that is a federally qualified health center or a federally qualified county clinic and has at least one registered nurse staffed onsite at the facility at all times.

1814.
 “Community paramedic” means a paramedic licensed under this division who has completed the core curriculum for community paramedic training described in paragraph (1) of subdivision (d) of Section 1831, has received certification in one or more of the community paramedicine program specialties described in subdivisions (a) to (e), inclusive, of Section 1815, and is accredited to provide community paramedic services by a local EMS agency as part of an approved community paramedicine program.

1815.
 “Community paramedicine program” means a program developed by a local EMS agency and approved by the Emergency Medical Services Authority to provide community paramedic services consisting of one or more of the program specialties described in subdivisions (a) to (e), inclusive, under the direction of medical protocols developed by the local EMS agency that are consistent with the minimum medical protocols established by the authority. Community paramedic services may consist of the following program specialties:
(a) Providing short-term postdischarge followup for persons recently discharged from a hospital due to a serious health condition.
(b) Providing directly observed therapy to persons with tuberculosis.
(c) Providing case management services to frequent emergency medical services users.
(d) Providing hospice services to treat patients in their homes.
(e) Providing patients with transport to an alternate destination facility.

1816.
 “Community paramedicine provider” means 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 local EMS agency.

1817.
 “Public agency” means a city, county, city and county, special district, or other political subdivision of the state that provides first response services, including emergency medical care.

Article  3. State Administration

1830.
 (a) The Community Paramedicine Oversight Committee is hereby created within the Emergency Medical Services Authority to advise the authority on, and approve minimum medical protocols for, the community paramedicine program specialties described in Section 1815.
(b) The committee shall consist of the following 11 members appointed by the Governor:
(1) Two full-time physicians and surgeons, whose primary practice is emergency medicine, from a list of five names submitted by the California Chapter of the American College of Emergency Physicians.
(2) Two registered nurses from a list of five names provided by the California Labor Federation.
(3) Two emergency medical technician paramedics from a list of five names provided by the California Professional Firefighters and the California Labor Federation.
(4) Two medical directors of local EMS agencies from a list of five names submitted by the EMS Medical Directors Association of California.
(5) One local EMS agency administrator from a list of three names submitted by the Emergency Medical Services Administrators Association of California.
(6) One inpatient hospitalist from a list of three names submitted by the California Hospital Association.
(7) One mental health professional from a list of three names provided by the California Psychiatric Association.

1831.
 (a) The Emergency Medical Services Authority shall develop, in consultation with the Community Paramedic Oversight Committee, regulations that establish minimum standards for the development of a community paramedicine program.
(b) The Commission on Emergency Medical Services shall review and approve the regulations described in this section before the authority adopts the regulations.
(c) The regulations described in this section shall be based upon, and informed by, the formation and implementation of the Community Paramedicine Pilot Program under Health Workforce Pilot Project No. 173.
(d) The regulations that establish minimum standards for the development of a community paramedicine program shall consist of all of the following:
(1) Minimum standards and core curriculum for community paramedic training.
(2) Minimum standards for the scope of practice for each community paramedicine program specialty described in Section 1815.
(3) A process for certifying a community paramedic who completes the core curriculum training described in paragraph (1).
(4) Minimum standards for approval, review, withdrawal, and revocation of a community paramedicine program.
(5) Minimum standards for collecting and submitting data to the authority to ensure patient safety that include consideration of both quality assurance and quality improvement. These standards shall include all of the following:
(A) Intervals for community paramedicine providers, participating health facilities, and local EMS agencies to submit community paramedicine data.
(B) Relevant program use data.
(C) Public posting of program analysis.
(D) Emergency medical response system feedback, including feedback from the emergency medical care committee described in subdivision (b) of Section 1797.272.
(E) If the community paramedicine program utilizes an alternate destination facility, consideration of ambulance patient offload times for both the alternate destination facility and existing emergency departments, the number of patients that are turned away, diverted, or required to be subsequently transferred to an emergency department, and identification of the reasons for turning away, diverting, or transferring the patient.
(F) An assessment of each community paramedicine program’s medical protocols or other processes.
(G) An assessment of the impact that implementation of a community paramedicine program has on the delivery of emergency medical services and response times in the local EMS agency’s jurisdiction.

1832.
 (a) The Emergency Medical Services Authority shall develop and, after approval by the Community Paramedicine Oversight Committee, establish minimum medical protocols for each community paramedicine program specialty described in Section 1815.
(b) The protocols described in this section shall be based upon, and informed by, the formation and implementation of the Community Paramedicine Pilot Program under Health Workforce Pilot Project No. 173, and further refinements provided by local EMS agencies during the course and operation of the pilot program.

1833.
 (a) The Emergency Medical Services Authority shall submit an annual report on the community paramedicine programs operating in California to the relevant policy committees of the Legislature. The authority shall submit its first report six months after the authority adopts the regulations described in Section 1831, and every January 1 thereafter for the next five years.
(b) The report may include recommendations for authorizing additional community paramedicine program specialties not authorized under this chapter, as it read on January 1, 2019, or recommendations for changes to, or the elimination of, community paramedicine program specialties that do not achieve the community health and patient goals expressed in Section 1801.
(c) (1) A report to be submitted pursuant to subdivision (a) shall be submitted in compliance with Section 9795 of the Government Code.
(2) This section shall be repealed six years after the authority adopts the regulations described in Section 1831.

1834.
 (a) The Emergency Medical Services Authority shall review a local EMS agency’s proposed community paramedicine program to ensure it is consistent with the authority’s regulations and the provisions of this chapter.
(b) The authority may impose conditions as part of the approval of a community paramedicine program that the local EMS agency is required to incorporate into its program to achieve consistency with the authority’s regulations and the provisions of this chapter.
(c) The authority shall approve, approve with conditions, or deny the proposed community paramedicine program within six months after it is submitted by the local EMS agency.

1835.
 A community paramedicine pilot program approved under Health Workforce Pilot Project No. 173 before January 1, 2019, is authorized to continue operations until six months after the regulations described in Section 1831 become effective.

Article  4. Local Administration

1840.
 A local EMS agency may develop a community paramedicine program that is consistent with the Emergency Medical Services Authority’s regulations and the provisions of this chapter and submit it to the authority for approval pursuant to Section 1834.

1841.
 A local EMS agency that opts to develop a community paramedicine program shall do all of the following:
(a) Integrate the proposed community paramedicine program into the local EMS agency’s emergency medical services plan described in Article 2 (commencing with Section 1797.250) of Chapter 4.
(b) Consistent with this article, develop a process to select community paramedicine providers at a periodic interval of no more than 10 years.
(c) (1) Enter into an agreement with a community paramedicine provider for the delivery of community paramedic services within the local EMS agency’s jurisdiction that are consistent with the proposed community paramedicine program.
(2) A local EMS agency shall not include a community paramedic services agreement within an existing or proposed contract for the delivery of emergency medical services within an exclusive operating area described in a contract awarded pursuant to Section 1797.224 or the provision of, or administration of, emergency medical services authorized pursuant to Section 1797.201.
(d) If the community paramedicine program provides the program specialties described in subdivisions (a) to (d), inclusive, of Section 1815, the local EMS agency shall enter into an agreement for the provision of those specialties according to the following:
(1) A local EMS agency shall solicit every public agency that is located within its jurisdiction to provide the proposed community program specialties. If a public agency agrees to provide all of those specialties, the local EMS agency shall enter into a written agreement with the public agency to provide those specialties.
(2) If a public agency agrees to provide only some of the proposed community program specialties, the local EMS agency may establish a competitive bid process to select a community paramedicine provider to deliver the specialties not provided by the public agency.
(3) If no public agency chooses to provide the proposed community program specialties, the local EMS agency shall establish a competitive bid process to select a community paramedicine provider to deliver the specialties.
(e) If the community paramedicine program provides the program specialty described in subdivision (e) of Section 1815, the local EMS agency shall do all of the following:
(1) Enter into an agreement that continues the use of existing providers operating within the local EMS agency’s jurisdiction in the manner and scope in which that service has been provided by the existing provider pursuant to Section 1797.201 or Section 1797.224.
(2) Certify that the alternate destination facility authorized to receive patients has adequate licensed medical staff, facilities, and equipment that comply with the requirements of the Emergency Medical Services Authority’s regulations and the provisions of this chapter.
(3) Collaborate with the emergency medical care committee to develop medical protocols that describe when the use of an alternate destination facility is in the best interests of the patient and, upon approval of the medical director of the local EMS agency, submit the protocols to the Emergency Medical Services Authority. The medical protocols shall be consistent with the requirements of the authority’s regulations and the provisions of this chapter, and may include provisions describing the following:
(A) Qualified staff to care for the degree and severity of a patient’s injuries and needs.
(B) The equipment and services available at an alternate destination facility necessary to care for patients requiring medical services.
(C) The time of day and any limitations that may apply for an alternate destination facility to treat patients requiring medical services.
(4) Secure an agreement with the alternate destination facility that requires the facility to notify the local EMS agency and the Emergency Medical Services Authority within 24 hours if there are changes in the status of the facility with respect to the protocols and the facility’s ability to care for patients.
(5) Secure an agreement with the alternate destination facility attesting that the facility will operate in accordance with Section 1317 and providing that failure to comply with Section 1317 will result in the immediate termination of use of the facility as part of the community paramedicine program.
(f) Establish a process for training and certification of community paramedics in the proposed community paramedicine program’s specialties.
(g) Facilitate and participate in any agreements between a community paramedicine provider and public or private health system participants to provide funding to support the implementation of the local EMS agency’s community paramedicine program.

Article  5. Miscellaneous

1850.
 A person or organization shall not provide community paramedic services or represent, advertise, or otherwise imply that it is authorized to provide community paramedic services unless it is expressly authorized by a local EMS agency to provide those services as part of a community paramedicine program approved by the Emergency Medical Services Authority.

1851.
 A community paramedic shall provide community paramedic services only if he or she has been certified to perform those services by a local EMS agency and is working as an employee of an authorized community paramedicine provider.

1852.
 The disciplinary procedures for a community paramedic shall be consistent with subdivision (d) of Section 1797.194.

1853.
 Entering into an agreement to be a community paramedicine provider pursuant to this chapter shall not alter or otherwise invalidate a public agency’s authority to provide or administer emergency medical services pursuant to Section 1797.201 or 1797.224.

1854.
 The liability provisions described in Chapter 9 (commencing with Section 1799.100) shall also apply to this chapter.

SEC. 3.

 No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.
SECTION 1.

It is the intent of the Legislature to enact legislation that establishes statewide guidelines for, and authorizes the implementation of, community paramedicine programs in California that utilize existing providers, promote continuity of care, and maximize existing efficiencies within the first response and emergency medical services system.