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HomeMy WebLinkAboutMINUTES - 05061997 - D4 F&HS-03 TO: BOARD OF SUPERVISORS ,,E. S;... FAMILY AND HUMAN SERVICES COMMITTEE . � � Contra FROM: COSI (Q o•. _ :_<,,�'---= ;rte April 28, 1997 -x �'� County �. DATE: cO'srq couN� REPORT ON EMERGENCY MEDICAL SERVICES SUBJECT: SPECIFIC REQUEST(S)OR RECOMMENDATION(S)6 BACKGROUND AND JUSTIFICATION RECOMMENDATIONS: 1. ACCEPT this report from the Family and Human Services Committee in response to the Board's direction to our Committee to report back within 30 days on this subject. 2. LEAVE this subject matter on referral to the Family and Human Services Committee, REQUEST the Family and Human Services Committee to review this matter again in June. 3. AGREE to have the Emergency Medical Care Committee report, at least temporarily, to the Board of Supervisors rather than the Health Services Director. BACKGROUND: On April-22, 1997, the Board of Supervisors approved a report from our Committee on this subject which included the following recommendations: 1. DIRECT the Health Services Director to respond as fully as possible to the - directions from the Board of Supervisors on April 8, 1997,to the Family and Human Services committee on April 28, 1997. CONTINUED ON ATTACHMENT: YES SIGNATURt?II RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOA OMMITTEE a APPROVE 0 V' MARK DeSAULNIER DONNA GERBE SIGNATURES ACTION OF BOARD ON APPROVED AS RECOMMENDED_XX_ OTHER 4 VOTE OF SUPERVISORS 1 HEREBY CERTIFY THAT THIS IS A TRUE XXUNANIMOUS(ABSENT AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. CC: ATTESTED May 6 , 1997 See Page 4 PHIL BATCHELOR,CLERK OF THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR M382 (10188) BY_�_ Ate !,-� ,DEPUTY F&HS-03 2. DIRECT the County Counsel to~respond as fully as possible to the directions from the Board of Supervisors on April 8, 1997, to the Family and Human Services Committee on April 28, 1997. 3. DIRECT the Health Services DirectorV and County Counsel to jointly advise the Family and Human Services Committee on April 28, 1997 of authority the Board of Supervisors or EMS Agency already has under current State law to further regulate elements of the emergency medical services system which is not currently being exercised. 4. DIRECT the Health Services Director to outline for the Family and Human Services Committee on April 28, 1997 the composition and membership of the Facilities Sub-Committee of the Emergency Medical Care Committee and the role of that Sub-Committee. 5. DIRECT the Health Services Director to outline in at least a preliminary manner additional legislation the Health Services Director recommends the Board pursue which would improve the emergency medical services system in Contra Costa County and forward his suggestions to the Family and Human Services Committee on April 28, 1997. It is our understanding that the actions taken by the Board of Supervisors on April 8, 1997, included the following: 1. Direction to County Counsel to prepare an opinion regarding what right the Board has to require that providers continue to offer emergency and/or intensive care services. 2. Direction to the Health Services Director to send a letter to all hospitals in Contra Costa County asking that they voluntarily freeze their current status and levels of service for emergency room and intensive care services pending a report from the Family and Human Services Committee on the referral requested by Supervisor Uilkema (expected within 30 days of April 8, 1997). 3. Adopt the referral to the Family and Human Services Committee pursuant to Supervisor Uilkema's request of April 1, 1997. 4. Direction to County Counsel to prepare an opinion on the authority of the Board, as a purchaser of health care services, to require that services which were understood to be available to the County's employees remain available during the period of the County's contract with Kaiser (or other providers). On April 28, 1997, our Committee met with the Health Services Director, Dr. William Walker; the Director of Emergency Medical Services, Art Lathrop; Lynn Baskett, Regional Vice President of the Hospital Council of Northern and Central California; Gary Sloan, Chief Executive Officer of Brookside Hospital and Doctor's Hospital of Pinole; Vickie Dawes, Deputy County Counsel; Bob Eisenman, representing Kaiser- Permanente and other interested individuals, including members of the 1996-97 Grand Jury. Dr. Walker briefly summarized the attached report from his office, noting that the letters the Board had asked to be written have been written, the Facilities Subcommittee of the Emergency Medical Care Committee met on April 25 on this subject, the Hospital Council is conducting a survey of ICU beds, and other issues are being addressed as is outlined in his report. -2- F&HS-03 Vickie Dawes, Deputy County Counsel, summarized her report. She indicated that there is very little the Board of Supervisors can do to require a hospital to maintain an emergency room. Even as a purchaser of health care services, any changes to the County's contract with Kaiser would require agreement by both parties while the contract is in effect. Art Lathrop, Director of Emergency Medical Services, indicated that the Facilities Subcommittee of the Emergency Medical Care Committee met on April 25. The hospital facilities recognize that there is a significant community concern that needs to be addressed. There is recognition that the facilities need to cooperate with each other and with the County to address some of these issues. The Facilities Subcommittee is going to address two subjects: a facilities assessment of the hospitals in the County, and ambulance and transfer issues. Task Forces have been appointed for this purpose. Lynn Baskett from the Hospital Council noted that the initial numbers show that there has been an increase of 3 in licensed critical care beds between 1995 and 1997. There are also further increases scheduled later this year. Other details will be available as the results of the surveys are tallied. Gary Sloan reported that since he has been on board in January several steps have been taken to improve service to the public. Brookside has historically had long waits in the emergency room. This has been relieved by increasing the number of ICU beds from 23 to 30 and will be further,relieved by adding an additional 20 monitor beds to the 12 monitor beds that are presently available. There have also been problems with over-utilization of ICU beds. Mr. Sloan noted that they are prepared to hold off making further changes to their emergency room capacity for 60 days. However, he raised the question of what the Board of Supervisors plans to do if it concludes that additional ICU beds are needed in the County. Dr. Walker clarified that a monitor bed is simply able to monitor the heart and is used for cardiac cases. Mr. Sloan also noted that the availability of ICU beds is a seasonal problem. During December, January and February there is an increased need for ICU beds. The existing supply of ICU beds is generally sufficient for the balance of the year. Bob Eisenman reported on behalf of Kaiser that the State Department of Health Services did a survey of Kaiser's Richmond facility on behalf of HCFA (the Health Care Financing Administration of the U.S. Department of Health and Human Services) and found some deficiencies. Kaiser has submitted a plan of correction and has taken several steps to correct the deficiencies and has asked for a follow-up survey the first week of May. He also agreed that Kaiser would comply with the 60- day moratorium requested by the County unless patient safety requires that some other steps.be taken. Supervisor Gerber indicated that it is essential that we talk about staffed ICU beds rather than licensed beds. Mr. Sloan indicated that his numbers'represent staffed beds. Ms. Baskett noted that their survey refers only to licensed beds and that it may be difficult to obtain information on staffed beds because of patient census fluctuations and how quickly a hospital may be able to staff beds which are not staffed at the current moment. -3- F&HS-03 Supervisor Gerber also distributed a draft of a letter to all hospital facilities in Contra Costa County and Alameda County which will be signed by most if not all members of the two counties' boards of supervisors, and State and Federal delegations. The letter asks that facilities delay any plans to reduce, downgrade, or consolidate current emergency and critical care services for a period of 90 days from receipt of the letter. Mr. Sloan suggested that the 90-day limit be modified to 60 days. Supervisor DeSaulnier noted that in his opinion the Board's role in all of this is educational and that the Board of Supervisors needs to exercise leadership in letting the public know what emergency medical services are available to them. cc: County Administrator Health Services Director Art Lathrop, Director, Emergency Medical Services, HSD Lynn Baskett, Regional Vice President Hospital Council of Northern and Central California 7901 Stoneridge Drive, Suite 500 Pleasanton, CA 94588 Gary Sloan, Chief Executive Officer Brookside Hospital 2000 Vale Road San Pablo, CA 94806 Bob Eisenman, Ph.D. Director, External Affairs Kaiser Permanente 1425 S. Main Street Walnut Creek, CA 94596 -4- Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Jim Rogers,1st District g_6 L-,o� William B.Walker,M.D. Gayle B.Uiikema,2nd District Director&Health Officer Donna Gerber,3rd District Mark DeSaulnier,4th District 20 Allen Street Joseph Canciamllle,5th District of a;;a;n - Martinez,California 94553-3191 (510)370-5003 County Administrator ` _— G�4o FAX(510)370-5099 Phil Batchelor osTA coffin. County Administrator April 24, 1997 To: Family and Human Services Committee From: William B. Walker, M.D. Subj: Report on Emergency Medical Services The following report responds to emergency medical services issues raised by the Board of Supervisors on April 8, 1997, and referred to your committee; responds to issues raised by your committee in your meeting of April 14, 1997; and provides additional information on the Department's actions in response to concerns about hospital emergency and critical care services. 1. A summary of county regulatory authority involving hospital emergency services as found in the EMS sections of the Health and Safety Code is as follows: (Note that County Counsel is separately responding to the issue of - county regulatory authority with respect to other code sections.) (a) "Designated facility" means a hospital which has been designated by a local EMS agency to perform specified emergency medical services system functions pursuant to guidelines established by the State EMS Authority. [1797.67] (b) Local EMS agency medical director may set patient destination policies for basic life support emergency medical transportation services. [1797.220] (c) County, upon recommendation of local EMS agency, may adopt ordinances governing patient transport from field by prehospital emergency medical personnel when patients meet specific criteria for trauma, burn, or pediatric centers. [1797.222] (d) A local EMS agency which utilizes receiving facilities not having a basic emergency medical services special permit is required to develop Merrithew Memorial Hospital&Healtlt Centers - Public Health - Mental Health - Substance Abuse - Environmental HeeMh Contra Creta Hearth Plan - Emergency Medical Ser Aces - Home Headh Agency Gedatrice A-345 (2/97) protocols addressing patient safety and use of the nonpermit facility. [1798.101(b)(2)] (e) A local EMS agency may plan and implement a trauma care system, including designation of trauma facilities. [1798.162-1798.169] (f) A local EMS agency may develop triage and transfer protocols to facilitate prompt delivery of patients to appropriate designated facilities within and without its area of jurisdiction. Considerations in designating receiving facilities shall include (a) hospital's consistent ability to provide on-call physicians and services for all emergency patients regardless of ability to pay, (b) sufficiency of hospital procedures to ensure all patients are examined and evaluated, and (c) hospitals compliance with local EMS protocols, guidelines, and transfer agreement requirements. [1798.170] (g) The local EMS agency shall establish guidelines and standards for completion and operation of formal transfer agreements between hospitals with varying levels of care. [1798.172] (h) A local EMS agency may develop an EMS for Children (EMSC) program which includes the assessment of hospital pediatric capabilities and development of protocols for transport and transfer of pediatric patients. [1799.205] (2) The Health Services Director-has written to each hospital within the county requesting that emergency and critical care services be kept at or above current levels pending completion of a report to the Board from the Family and Human Services Committee, said report to be made within 30 days of the Board's April 8th action. (3) The Health Services Director has written to the State Commissioner of Corporations Keith Bishop expressing the Board's concern over the closing of hospital intensive care units and requesting that the State Department of Corporations undertake an investigation of the appropriateness of California HMO's which have hospital facilities closing or eliminating intensive care unit (ICU) and emergency department (ED) services in facilities which attract their members but which cannot provide necessary emergency services. (4) The Health Services Director has written to State Department of Health Services Director Kimberly Belshe expressing the Board's concern over the closing of hospital intensive care units within the county and requesting that the State Department of Health Services undertake an investigation of the adequacy of having one acute care facility (Walnut Creek) in Contra Costa County to provide emergency and ICU services for over 300,000 Contra Costa Kaiser members. 2 (5) The EMS Agency has asked the Facilities and Critical Care Standing Committee of the Emergency Medical Care Committee (EMCC) to consider and make recommendations on the following: - Development of an online system for tracking hospital critical care resources. - A facilities assessment survey to be conducted by the EMS Agency. - Establishment of receiving facility agreements. - Ambulance diversion. - Standards for ambulance receiving facilities not holding basic emergency services permits. - Interfacility transfer agreements. - Ambulance availability for interfacility transfers, including staffing. The Facilities and Critical Care Committee will meet April 25th. A copy of the Committee participants is attached. (The EMCC is an advisory committee to the Health Services Director on emergency medical services issues. One function of the EMCC is to review the EMS System Plan annually. Several standing committees focusing on functional areas within EMS assist in carrying out this review.) (6) The EMS Agency, with the assistance of the Hospital Council of Central and Northern California, has undertaken a survey of hospital ICU resources including identification of problems and trends related to unavailability of ICU resources. (7) Department staff have discussed the use of "standby" emergency designation with DHS Licensing staff. DHS shares our concerns regarding the use of the standby designation within urban areas and is preparing a position on this. More information is expected to be available on the DHS position by April 29th. (8) Department staff have met with Kaiser representatives on the status of the Richmond facility. Kaiser Richmond is currently maintaining its standby emergency services, but is directing admissions to Brookside or to Kaiser- Oakland. The EMS Agency, as of April 18th, began diverting all emergency ambulance traffic (Code 2 and Code 3) to other facilities. Kaiser will submit a report to the EMS Agency by the first week of May detailing any violations of their emergency department staffing commitment made in 1995. Kaiser has 3 indicated that staffing schedules were consistent with the commitment, but is checking further to determine if actual staffing levels were consistent with scheduled staffing levels. (9) The EMS Agency is revising its transfer review procedures and patient transfer form to require that a patient transfer form be completed and sent to the EMS Agency by the sending facility for all patients transferred from an emergency department to another facility. EMS review will focus on transport related issues. (10) At this point, we believe that it would be prudent to wait for the release of the HCFA report and for a response from DHS and DOC before proposing any legislative solutions. attachment 4 Contra Costa County Health Services Department Emergency Medical Services Agency EMERGENCY MEDICAL CARE COMMITTEE FACILITIES/CRITICAL CARE STANDING COMMITTEE Bev Jones, Chairperson John Muir Medical Center VP, John Muir Medical Center 1601 Ygnacio Valley Road, Walnut Creek, CA 94598 Lynn Baskett Hospital Council of Northern & Central California Regional Vice President 7901 Stoneridge Dr. Ste 500, Pleasanton, CA 94588 Ellen Leng, MD Sutter Delta Medical Center Emergency Physician Representative 3901 Lone Tree Way, Antioch, CA 94509 Carol Fraser, RN San Ramon Regional Medical Center Emergency Nurses' Asso. Representative 6001 Norris Canyon Road, San Ramon, CA 94583 Vicki Gallagher Mt. Diablo Medical Center Base Hospital Representative P.O. Box 4110, Concord, CA 94524-4110 Kristi Gaub, RN John Muir Medical Center Trauma Center Representative 1601 Ygnacio Valley Road, Walnut Creek, CA 94598 Elliott Nipomnick, MD Brookside Hospital Emergency Department Physician 2000 Vale Road, San Pablo, CA 94806 Hope Freidman, FNP Children's Hospital Outreach Coordinator 747 52nd Street, Oakland, CA 94609 Michael Donnelly, RN Merrithew Memorial Hospital Nurse Manager, Emergency Department 2500 Alhambra Avenue, Martinez, CA 94553 Anne Martinez, RN Kaiser Permanente Nurse Manager, Emergency Department 1425 South Main Street, Walnut Creek, CA 94596 Jirayr Roubinian, MD Kaiser Permanente Emergency Department Medical Director 901 Nevin Avenue, Richmond, CA 94804 Susan Bumatay Sutter Delta Medical Center Assistant Administrator 3901 Lone Tree Way, Antioch, CA 94509 Charles Hamilton c/o EMS Agency EMCC Consumer Representative 50 Glacier Drive, Martinez, CA 94553 Gary Sloan Brookside Hospital Chief Executive Officer 2000 Vale Rd, San Pablo, CA 94806 Mike Melewitz, MD Kaiser Permanente Physician-in-Chief 1425 South Main St., Walnut Creek, CA 94596 Bob Eisenman, PhD Kaiser Permanente Director, External Affairs 1425 South Main St., Walnut Creek, CA 94596 Bob Weber American Medical Response Operations Director 2490-A Arnold Industrial Way, Concord, CA 94520 Kim Wood, RN American Medical Response Clinical/Education Coordinator 2490-A Arnold Industrial Way, Concord, CA 94520 Gayle DiMaggio Kaiser Permanente Medical Group Administrator 901 Nevin Ave., Richmond, CA 94504 Flo Raskin Kaiser Permenente Continuing Care Team Leader 280 W. MacArthur Blvd, Oakland, CA 94611 Mary Fitzsimons, MD Sutter Delta Medical Center Emergency Department Chief 3901 Lone Tree Way, Antioch, CA 94509 Bobbi Bonnet, RN EMS Prehospital Coordinator CCC EMS Agency Standing Committee Staff 50 Glacier Drive, Martinez, CA 94553 4/24/97 COUNTY COUNSEL'S OFFICE CONTRA COSTA COUNTY MARTINEZ, CALIFORNIA Date: April 24, 1997 To: Family and Human Services Committee From: Victor J. Westman,Cou sel 13y: Vickie L. Daw ty County Counsel Re: Regulation of Emergency Medical Care Services On April 8, 1997, the Board of Supervisors referred to the Family and Human Services Committee the issue of regional planning for the availability of emergency medical services at the Kaiser facilities in Martinez and Richmond. On April 14, 1997, the Family and Human Services Committee requested a legal opinion from this office on the right or authority of the Board of Supervisors to require a health care provider to continue to offer emergency and intensive care medical services at a particular medical facility, both in the Board's official capacity and in its capacity as a purchaser of health care services for its employees. We have reviewed the various statutes,regulations, and contracts on this subject, and we have spoken to representatives of the County Health Services Department,including the Emergency Medical Services Division and the Contra Costa Health Plan, and representatives of the California Department of Health Services(DHS) and the Department of Corporations(DOC). In our review of the statutes and regulations, we did not find any legal regulatory authority which.the County could exercise to require a private hospital to continue to provide emergency medical services and/or intensive care services to the community at large or to its health plan members. We spoke with a Los Angeles County Deputy County Counsel who provides legal advice to the Los Angeles County Health Services Department. He expressed the view that a county has no legal authority to regulate the type or quantity of services offered by a private hospital within the jurisdiction of that county. "rhe County is required by Health and Safety Code section 101000 to appoint a health officer. It is the responsibility of the County Health Officer to"take measures as may be necessary to preserve and protect the public health in the unincorporated territory of the county,including,if indicated,the adoption of ordinances, regulations and orders not in conflict with general laws ,.. ." (Health and Saf. Code §101025.) We spoke with Dr. Walker about this general issue and Dr. Walker indicated that he was not aware of any authority for the County to direct Kaiser, or any other non-county facility,to maintain an emergency department in a particular medical facility. We did not discuss with Dr.Walker the powers and authority of the health officer as it might relate to this issue. However, Dr. Walker indicated that the California Department of Health Services and/or the California Department of Corporations might have some authority over the downgrading/closure of emergency services at general acute care hospitals. Family and Human Services Committee -2- April 24, 1997 Mr. Art Lathrop,Emergency Medical Services Director,has indicated that there may be certain limited powers vested in the Emergency Medical Services Division which might be exercised in this regard pursuant to Health and Safety Code sections 1797, et seq., and Mr. Lathrop will be making a separate report on his review and findings. The State Department of Health Services"may advise all local health authorities, and, when in its judgment the public health is menaced,it shall control and regulate their action." (Health and Safi. Code §100180.) Further, we are advised by Mr. Gil Martinez of the Licensing and Certification Division of the State Department of Health Services that DHS is in the process of analyzing the applicable statutes to determine the scope of DHS authority over the closure and/or downgrading of emergency departments in general acute care hospitals. In particular,DHS is well aware of the Kaiser situation,since DHS recently conducted a review of three patient deaths at Kaiser- Richmond on behalf of the U. S. Health Care Financing Administration (HCFA). This review resulted in an order to Kaiser to correct certain problems at the Richmond and Oakland facilities by May 7th or lose its MediCal and Medicare funding. According to Mr. Martinez, DHS is considering three options on the general issue of downgrading/closure of emergency medical services by general acute care hospitals. DHS expects to develop an official position on this issue in the next four to six weeks. The three options are as follows: 1. Allow the marketplace to set the level and location of emergency medical services. 2. Develop standards and criteria to determine when and to what extent a general acute care hospital may downgrade/close its emergency department. (See Health and Saf. Code§§ 1256.1 and 1300.) 3. Develop standards for notifying the public of pending emergency department downgrades/closures in order to minimize the impact of the process on the public. The Department of Corporations(DOC)governs those health plans which are qualified pursuant to the Knox-Keene Igcalth Care Service Plan Act . (Health and Saf. Code §§ 1340, 1.341.) Both Kaiser and Contra Costa Health Pian are Knox-Keene qualified health plans. A Knox-Keene qualified health plan that wants to change its health care delivery system must notify the DOC of the proposed change. (Cal. Code Regs.,tit. 10, §1300.513.) In the case of a qualified Knox-Keene health plan,emergency services must be reasonably accessible to its health plan members. (Cal. Code Regs., tit. 10, §1300-51.) After reviewing the Knox-Keene Health Care Service Plan Act and consulting with Milt Camhi, Contra Costa Health Plan Director, and with Anita Osteroff, counsel for the Department of Corporations, we have concluded that it is not necessary for a Knox-Keene qualified health plan to build and maintain a general acute care facility (with or without an emergency department) in order to provide reasonable access to emergency services to its health plan members. Such access may be provided by contracting with a facility with an emergency department located within the health plan service area. (Ms. Osteroff declined to discuss the Kaiser situation with its Martinez and richmond facilities.) Family and Human Services Committee -3- April 24, 1997 This office also reviewed the 1997 contract between Kaiser and Contra Costa County wherein the County is a purchaser of health care services on behalf of its employees. (The 1997 contract was approved by the Board.of Supervisors on October 22, 1996.) The Kaiser contract provides that emergency medical services is a covered service,however,the contract does not specify that emergency services will be available at any particular Kaiser-operated facility. (See Section 11,paragraph A.) The contract with Kaiser became effective on January 1, 1997 and continues in effect for one year, and from year to year thereafter unless terminated. The contract may be terminated by giving written notice to Kaiser at least 60 days prior to the yearly anniversary date,by mutual agreement,or by Kaiser if Kaiser determines that it is impractical or impossible to continue to provide the services covered by the agreement. (See"Face Sheet"and Section 9 of the 1997 Kaiser Contract.) The contract".Amendment Procedure"provides that Kaiser m ay amend any provision of the contract by mailing notice of the amendment to the County at least 60 days before the contract anniversary date. (See "Face Sheet.") There is no comparable provision which allows the County to amend in such a manner, but the power to amend by mutual agreement is provided for in the following sentence from the contract: "However, this Agreement is subject to amendment, modification or termination in accord with any provision hereof or by mutual agreement between Health Plan and Group[i.e.County]without the consent or concurrence of Members." (Section 10.B.) The Memoranda.of Understanding between the County and each labor union which is a member of the Labor Coalition provide that the County "will continue the existing County Group Health Plan program of medical,dental and life insurance coverage through Delta Dental Plan,Safeguard Dental Plan, Aetna Life Insurance and the medical insurance options of Kaiser-Permanente Foundation Health Plan, to all permanent employees ... ." These MOU's do not expire until September 30, 1999. The California Department of Health Services and the U. S. Health Care Financing Administration are acutely aware of the situation with the Kaiser emergency departments in Contra Costa County. We recommend that the Board of Supervisors direct the County Health Department to cooperate with these agencies in their investigation and monitoring of Kaiser's provision of emergency medical services. VLD:ld W aAkaiieccros TOTAL P.004