Supervisors approve ambulance agreements for SDCFPD

Joe Naiman

Village News Reporter

The San Diego County Board of Supervisors, who are also the board members of the San Diego County Fire Protection District, have given the SDCFPD the primary responsibility for ambulance services within the SDCFPD boundaries.

On behalf of the Board of Supervisors, the 4-0 vote May 23, with one vacant seat, authorized the county’s chief administrative officer or her designee to enter into a contract with the San Diego County Fire Protection District for exclusive provision and/or management of emergency ambulance services in the areas where the county has or will have the responsibility for ambulance transportation services and to approve any amendments to the contract.

Acting as the fire district, the 4-0 vote approved a resolution authorizing the California Health and Safety Code statutory requirements to be included in all subcontracts and governing interactions with private ambulance employees, authorized the SDCFPD fire chief or his designee to enter into a written contract with the county for the provision of ambulance services and to approve contract amendments, authorized the fire chief or designee to take any necessary actions to implement the agreement, and authorized SDCFPD staff to issue competitive solicitations to provide ambulance transportation services in the county’s Unified Service Area and to award contracts.

The county's backcountry area includes desert and mountainous terrain, winding and narrow roads, driveways and other areas which are not well mapped, and occasional weather constraints including extreme heat, fog, snow and ice. Many backcountry communities have relatively few residents but numerous seasonal and weekend visitors for recreational activities.

Many of the county's residents have ambulance service provided by their city, fire district, or other agency, but many unincorporated communities are served by ambulance service providers contracted by the County of San Diego. The contractors are selected through a competitive process to provide ambulance service in specific operating areas.

In April 2017, the county supervisors directed the chief administrative officer to conduct a study to improve emergency medical services in the unincorporated county's backcountry. In December 2017 the supervisors voted to accept the study and approve the initiation of the proposed implementation plan including emergency medical service (EMS) boundary adjustments and the authorization of competitive bids to provide paramedic ambulance service in the Unified Service Area.

At the time, the four existing contract areas were the Valley Center Service Area, the Julian Service Area, the Grossmont Healthcare District Zone 2 Rural and Otay Mesa Service Area, and the Ocotillo Wells, Anza Borrego State Park and Surrounding Desert Communities Service Area.

In six areas – the DeLuz, San Pasqual, Ramona, Sycamore Canyon, El Capitan, and Southern Desert areas – no provider was specifically designated to provide ambulance service with mutual aid agreements being used to service those areas. Those 10 areas total more than half of the county's land.

The analysis of service delivery in the contract and undesignated areas focused on ensuring the prompt arrival of care, ensuring that all parts of San Diego County have an assigned advanced life support ground ambulance provider, supporting further integration of emergency service delivery with fire service delivery, supporting more robust performance management and operational efficiency, facilitating more meaningful EMS mutual aid reciprocation where not currently feasible, and examining methods by which services are provided including ground, fire department, and air ambulance services.

The findings of the analysis included that population density and distribution was changing in the study area, that the number of 911 responses for emergency medical assistance was increasing in the study area (approximately 11,000 responses were expected for calendar year 2018) and that a majority of the calls for emergency medical assistance in the study area were related to trauma or to neurological issues (cardiopulmonary resuscitation or other chest pain or respiratory issues accounted for approximately 19% of calls).

More findings are that more timely medical intervention by EMS personnel could lead to better patient outcomes, that ambulance response time standards varied within the operating area, that services were frequently provided by mutual aid in the study area in which case the provider was not bound to specific response time standards and that technology provided opportunities to monitor the EMS system and improve performance.

Also, that the county's Health and Human Services Agency (HHSA) subsidized EMS service delivery to varying degrees in the study area, that changes to fire service operations created new opportunities for coordination, and that boundaries for exclusive operating areas required revision to ensure countywide paramedic coverage.

Based upon the findings, HHSA proposed an alternate service delivery model to provide better access and quality for EMS services in the study area. A Unified Service Area integrated the four operating areas and six undesignated areas; although operating areas remained in place, future procurements for ambulance services allowed providers to propose services for all or part of the Unified Service Area.

The boundaries of the Unified Service Area were adjusted to create Inland North (including DeLuz and San Pasqual), Inland Central (including Ramona, Ocotillo Wells, and Southern Desert), and Inland South (including Sycamore Canyon and El Capitan) areas.

The features of the Unified Service Area concept included updating response time standards to reflect population patterns and integration of EMS and fire services, using new technology to establish updated performance management standards, streamlining the practice for HHSA to subsidize ambulance service, and developing a procurement for a Unified Service Area delivery model which aligned ambulance service contract dates.

The December 2017 action included authorization for the director of the county's Department of Purchasing and Contracting to issue competitive solicitations for paramedic ambulance service in the Unified Service Area and to award contracts initially from Jan. 1, 2020, to June 30, 2020, with up to five one-year options and up to an additional six-month option period. (The previous contracts either expired in 2019 or were extended to align their expiration with the other contracts.)

The response time standards for calls had been 10 minutes for urban areas (if a fire agency paramedic arrives within eight minutes the ambulance response time standard is 12 minutes) and 30 minutes for rural areas, but no standard other than "best effort response" existed for the undesignated areas. The new standards adopted in December 2017 are for cases in which no fire department advanced life support services are available.

The urban zone response standard remained at 10 minutes; the rural zone standard was reduced from 30 minutes to 16 minutes (20 minutes for ambulance arrival if a fire agency paramedic arrives within 15 minutes), and the "best effort" standard was replaced by response times of 25 minutes for outlying zones (30 minutes if a paramedic arrives within 23 minutes) and 45 minutes for desert zones (60 minutes if a paramedic arrives within 45 minutes). The eastern part of DeLuz has rural zone classification while the western part of DeLuz is an outlying zone.

Despite the enhancements approved in 2017, the remote location of communities, low transport revenue, and paramedic staffing challenges continued to hinder the viability of the ambulance transportation model. State legislation passed in 2021 includes 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.

A December 2022 Board of Supervisors action directed the chief administrative officer to hire a consultant to evaluate the optimal ambulance transportation service model within the Unified Service Area considering the statutory change and increased Medi-Cal payments to government-provided ambulance services as of January 2023.

Citygate Associates, LLC, was selected to conduct the review and evaluate fiscal sustainability, patient care, and operational objectives of a future ambulance services model. Citygate recommended that the SDCFPD assume responsibility as the ambulance service manager and provider when the current private ambulance services contracts end.

The authorization of the fire chief or designee to take any necessary actions to implement the agreement includes procurement of vehicles, equipment, training, space, and services. After responses to the competitive solicitation are reviewed and a fair and reasonable price is negotiated the contracts will be awarded for an initial term of nine months with nine one-year option periods and up to an additional six months if needed.