Testimony Regarding Proposed Regulation

James Hooley

Chief of Department, EMS

Testimony Regarding Proposed Regulation

105CMR173.000: Mobile Integrated Health Care and Community EMS Programs

Before the Department of Public Health

September 22, 2016

●My name is Jim Hooley and I am Chief of Boston EMS, the largest municipal EMS service in Massachusetts. We have approximately 350 EMTs and paramedics who respond to over 120,000 emergency medical incidents every year.

●Thank you for the opportunity to provide a testimony for the proposed regulation 105CMR173.000: Mobile Integrated Health Care and Community EMS Programs.

●Boston EMS has been a longstanding supporter of the advancement of EMS, many of the special project waivers we have sought and carried out have since been adopted as state practice, such as the use of Narcan by BLS providers.

●I believe Mobile Integrated Health Care and Community EMS Programs both represent a step in the right direction, although with the implementation of any new initiative, we must do our due diligence to ensure the language of the regulation clearly supports and defines the expectations for the two programs.

●In section 173.040 there is reference to measuring quality and cost effectiveness. While I see great value in having such measures, my personal experience has taught me that they can be challenging to monitor within the context of EMS service provision. I would encourage the Department of Public Health to provide additional detail regarding such expectations.

●While it is certainly cost effective to divert a patient from a hospital emergency department, there is still an expense associated with EMS providing a service to such patients. Currently, insurance reimbursement is relatively limited to ambulance transport to hospital emergency departments. We encourage the Department to provide more guidance on potential funding structures, including reimbursement from public and private payors to cover EMS costs, which may include allowing services to bill for care provided at home or for transporting patients to less costly points of care, such as community health centers.

●Along that vein, the regulation affords some flexibility with regard to EMS transport destinations including non-emergency departments. We encourage the Department to provide additional clarity as to whether this will solely apply to MIH programs or whether is it the intent of DPH to consider this more broadly.

●Although Boston EMS has seen an increase in calls and in patient transports, we often take measures to reduce demand and mitigate transports to emergency departments. For example, each year at the Boston Marathon, Boston EMS helps care for over one thousand patients at the finish area medical stations, ensuring that only the most critical are transported to a hospital. And, as a participant in the City’s Vision Zero taskforce to eliminate roadway fatalities and serious injuries, Boston EMS data is used to inform roadway improvement efforts.

●We also appreciate that a significant number of our emergency calls could be diverted from emergency room care, and our patients could potentially benefit from the flexibility to provide care more holistically.

●We also suggest that the Department consider a broader approach to defining high-value public health services with low risk preventative services to be provided under the Community Programs. Substance abuse prevention services, for example, may be an appropriate fit for this program.

●The current language of the regulation makes it clear the MIH program focuses on ED avoidance, as outlined in section 173.050, although it is at times unclear how the MIH and Community EMS programs differ, for example, we suggest more clarity with respect to the application process separate, whether a Community EMS program transition into an MIH program (or vice versa), and other specific programmatic differences, including settings for care delivery between the two programs.

●Specific to the Community EMS program, the application process itself appears to be relatively vague in the regulation language. Please consider including more detail in either final regulations or the application materials regarding these requirements.

●Within the MIH program, the language consistently refers to ‘Paramedics’ as the care providers, although in section 173.100 (9) (b), providers also include ‘other EMS personnel.’ I would encourage inclusion of AEMTs and EMTs, as there are many instances where they could provide services at their level of certification. At Boston EMS, in addition to their clinical skill, they hold a diverse array of cultural competencies, which could serve significant value for various health care interventions. Perhaps the skill-level determination could be made based on the proposed initiative, versus restricting the program to a single rank.

●Interestingly, within the language outlining the MIH program medical director’s role, there is a more expanded list of professions that may participate in the MIH program, including nurses, nurse practitioners, physician assistants and others, which are not referenced anywhere else in the regulation. It would be helpful to have clarification regarding how they would align with the MIH program and how they would work under the supervision of the medical director if they are part of another program.

●Another area I would suggest re-examining is the list of minimum standards, section 173.100, where it is unclear how certain items, such as anesthesia complications and fires relate to an MIH program. And, unlike health care facilities, it may take time before an EMS department learns of patient-related complications. The 5-day reporting requirement may also prove challenging if a service becomes aware of the incident outside this window.

●As a final note, I think we would be remiss if we did not acknowledge the importance of understanding the needs of the communities being served and encourage programs that promote services for those experiencing a disproportionate health burden. The MIH minimum requirements section 173.040 (A) (2) references identified gaps in service delivery, perhaps the following bullet could be added to the list: Interventions to promote health equity. Similarly, for the Community EMS Program Approval (173.060) segment, a bullet could be included under the responsibilities of the medical director, which states ‘Ensure the program takes into account the needs of the service population.’

●Thank you for your time, I would be more than happy to provide additional detail on any topic referenced in my testimony.