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Final Report    

ASSESSMENT  OF  

EMERGENCY MEDICAL SERVICES  IN  

SUBLETTE COUNTY, WYOMING  

June 2016   

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Table of Contents 

ExecutiveSummary 3I. Introduction&AssessmentMethodology 6II. OverviewofSubletteCounty 7III. OverviewoftheEMSSysteminSubletteCounty 12IV. DescriptionofSubletteCountyEMS 16 V. KeyObservations 21 VI. Recommendations 32AppendixA:WhatisCommunityParamedicine?   

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Executive Summary SafeTechSolutionsspentthreemonthsinthespringandsummerof2016studyingtheEMSsysteminSubletteCounty,Wyoming.Thisstudyfocusedonthelong‐termsustainabilityandreliabilityofSubletteCountyEMS.Thestudyincludedasitevisit;approximately20interviewswithkeystakeholders;extensiveresearchaboutSubletteCounty,theSubletteCountyRuralHealthCareDistrictanditsEMSsystem;thoroughanalysisofWyomingAmbulanceTripReportingSystemdata;andscrutinyofthefinancialandoperationaldataforSubletteCountyEMS.Basedonitsstudyandobservations,SafeTechSolutionsoffersthefollowingrecommendationstoSubletteCounty,SubletteCountyRuralHealthCareDistrict,andSubletteCountyEMS:1.CreateavisionandplanforEMSsuccessandsustainabilitythatincludesthefollowingelements:

Adescriptionofthelevel,quantityandqualityofEMSneeded,wantedandfundable. PrioritizationofEMSaboveotherlocalmedicalofferings. ApowerfulandreassuringstorytotellaboutEMS. Maximizationoftheuseofground‐basedEMS.

2.StrengthentheEMSorganizationalstructureandleadershipteamtosupportsustainabilityby:

ClarifyingtheEMSreportingstructureforEMSwithinthehealthcaredistrict. InvestingintheEMSleadershipteam’sknowledgeofEMSoperationsandfinance

andexposuretobestpractices. Ensuringtheleadershipteamiscommittedtotheorganizationanditsfuture.

3.Strengthenoperationalandfinancialefficiencybynarrowingthegapbetweenexpensesandrevenuesby:

Reducingthenumberofdeployedresourcestomatchanticipatedcallvolume. Developingandimplementinganewcallschedulethatreducesovertimeandissafe

andhumane. Raisingrevenuebyincreasingbillingrates,capturinglostrevenueandensuringall

patientsaretransportedtoahospital. Developingacapitalvehiclereplacementplan. Usingairmedicalresourcesefficiently.

4.Usedatatodrivedecisionsby:

Ensuringthatessentialdataisreliable,complete,andconsistentwithotherdatasources,suchasWATRS,billing,andthelocalcommunicationcenter.

Developingadashboardthatincludeskeyperformanceindicatorscriticalforsuccess.

Regularlymeasuringemployeeengagement.

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5.Continuetodevelophealthcareintegrationby:

ExploringwaystoexpandtheuseofEMSintonon‐911serviceswiththegoalofcreatingatrulyintegratedcaremodel.

Recommendationsarebasedonthefollowingkeyobservations.1.EMSisavitalandessentialelementofhealthcareandqualityoflifeinSubletteCounty.2.Asoperatingtoday,SubletteCountyEMSisnotsustainable.3.SubletteCountyEMSpossessesmanyelementsofaprogressiveandsustainableruralEMSsystem.

3A.BoththehealthcaredistrictandEMSdepartmenthavecapableleaders. 3B.TheEMSDirectorhasgoodbusinessandpeople‐managementskills. 3C.TheEMSsystemisimplementingdynamicdeploymentstrategies. 3D.TheEMSsystemprovidesahighlevelofqualityclinicalcare. 3E.EMSisadequatelyintegratedintothelocalhealthcaresystem. 3F.SubletteCountyEMShasaknowledgeableandcompetentbillingdepartment.

4.SubletteCountyEMSfacesmajorchallengesassociatedwiththelocaleconomyanditspositionwithinthehealthcaredistrict.

4A.SubletteCountyanticipatessharpreductionsintaxrevenues. 4B.EMSwillbeaffectedbychangeswithinthehealthcaredistrict. 4C.PerceptionsaboutthehealthcaredistrictmayhurtEMS. 4D.SubletteCountyEMSlacksaclearvisionandstrategicplan.

5.SubletteCountyEMSlacksclaritywithregardtoitsstructure,leadership,workforceanddatagathering.

5A.Thehealthcaredistrictreportingstructureneedsclarification. 5B.Departmentaljobdefinitionsandreportingstructureareweak. 5C.ThecurrentEMSleaderdoesnothavedeepoperationalandfinancialexperience

inEMS. 5D.EMSemployeeengagementisprecarious.

6.SubletteCountyEMSisnotoperatingefficientlynormaximizingitsrevenuefrompatientbilling,anditmayhavelittleornoincentivetodoso.

6A.Thecurrentschedulingsystemisnotefficient. 6B.TheEMSsystemhastoomanyresourcesforitscallvolume. 6C.Billingratesforpatienttransportsaretoolow. 6D.EMSislosingpotentialrevenuebytransportingpatientstodistrictclinics. 6E.EMSdoesnothaveacapitalreplacementplan. 6F.Thefrequentuseofairmedicalresourcesmaynotbeclinicallynecessaryor

operationallyefficient.

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6G.TheongoinghealthcaredistrictsubsidyoftheEMSservicemightserveasadisincentiveforimprovedorganizationalefficiencyandrevenuemaximization.

7.SubletteCountyEMSisfailingtodoanadequatejobofcollectingdataandanalyzinginformationaboutitsEMSsystem.

7A.SubletteCountyEMSdoesnothavebasiccalldata,andthedatathatitdoeshaveisatoddswithstate‐reporteddata.

7B.SubletteCountyEMSdoesnothavedefinedkeyperformanceindicators(KPIs). 7C.SubletteCountyhasnoformalorinformalprocessformeasuringEMSemployee

engagement. 7D.SubletteCountyhasnoformalmeasurementofEMScustomersatisfaction.

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I. Introduction & Assessment Methodology  LikemanyruralcountiesinAmerica,SubletteCounty,Wyoming,facesgrowingchallengesinmeetingitsout‐of‐hospitalemergencymedicalcareneeds.TheawarenessofthesechallengesandthedesiretoovercomethemledSubletteCountyRuralHealthCareDistricttofileanapplicationwiththeWyomingOfficeofEMSandTraumaforgrantmoneytofundanassessmentofEMSinSubletteCounty.SafeTechSolutions,LLP,wascontractedtoconducttheassessment.SafeTechSolutionsisanEMSconsultingfirmwithextensiveexpertiseevaluatingEMSorganizationsandassistinginthedevelopmentofruralambulanceservicesandsystems.SafeTechSolutionshasworkedwithruralWyomingEMSagenciesthroughitsEMSLeadershipAcademyandinassessmentsinSweetwater,Fremont,CampbellandCarbonCounties.ThegoalsoftheSubletteCountyassessmentprojectareto:

Evaluatethesustainability,reliabilityandlong‐termsurvivabilityofEMSinthecounty,includingthecurrentstructureandoperationsofSubletteCountyEMS;

Validatesystemcomponentsthatareworkingwell;and Makerecommendationsforchangeandimprovement,asneeded.

Theassessmentfocusesonlocalneeds,currentoperations,systemdesignandavailablesupportingresourceswithaneyeonsustainability.Thescopeoftheassessmentislimitedandwasnotanauditofoperations,financesorclinicalperformance.Airmedicalserviceisnotpartoftheassessment.MethodologySafeTechSolutions’assessmentteamusedaprocessofinquiryandinvestigationthatcapitalizesonthefirm’sextensiveunderstandingofruralEMSsystems.Itsprincipalsgatheredquantitativeandqualitativedatathroughresearch,sitevisits,andinterviews.SafeTechSolutionsconsultantsvisitedSubletteCountytoreviewdocumentsanddata,conductinterviewsandassessoperations.Inadditiontoevaluatingtheambulanceorganization(organizationalstructure,leadershipandoperations),SafeTechSolutionspaidspecialattentiontothesocial,economic,demographic,culturalandpoliticalissuesinSubletteCounty,carefullyanalyzingdataandmakingrecommendationsbasedonindustrybestpractices,aswellaswhatispracticalanddoableinSubletteCounty.Thisreportsummarizesthefindings,keyobservationsandrecommendationsforEMSinSubletteCounty.

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II. Overview of Sublette County SubletteCountycovers3.2millionacresinwesternWyoming.Of23countiesinthestate,SubletteCountyrankssixthingeographicalsize.TheWindRiverRangerunsnorthtosouthalongtheeasternportionoftheCounty,theGrosVentreWildernessliestothenorth,andtheWyomingRangerunsalongthewesternside.Thecentralportionofthecountyisavalleycomprisedofasagebrushsteppeeco‐region.Elevationrangesfrom6,280feetinthevalleyto13,400feetintheWindRiverRange.Thecountyhasmorethan1,300lakes.1Geographicallyisolatedfromrailroadsandpopulationcenters,SubletteCountyretaineditsfrontiercultureforfarlongerthanmanyareasofWyomingandtheWest.Itwasnotincorporateduntil1921,makingitthenewestcountyinthestate,andithasremainedoneoftheleastdenselypopulatedareasinthestatewellintothe20thcentury.Eventoday,80percentofSubletteCountylandispubliclyowned.SubletteCountyhasexperienceddramaticgrowthsince2000duetoenergydevelopment.Thecounty’spopulationincreasedfromfewerthanthan6,000residentsin2000tomorethan10,000residentsin2013.Populationgrowthsince2000(68percent)wasfourtimesthegrowthrateforWyoming(18percent)andsixtimesthegrowthratefortheU.S.(12percent).Mostoftheincreaseinpopulationoccurredfrom2002through2009whenpopulationincreasedatanaverageannualrateof7percentperyear.Since2009,thepopulationhasplateauedataround10,000residents,reflectingaslowdowninenergydevelopmentinthecounty.2SubletteCountyhasthreeincorporatedtowns:BigPiney,MarbletonandPinedale.SmallerunincorporatedcommunitiesincludeBondurant,Cora,BoulderandDaniel.Pinedaleisthecountyseat.3Nearly60percentofresidentsliveinruralpartsofthecounty.Theotherhalf                                                       1Sublettewyo.com2ASubletteCountyProfile:SocioeconomicsbytheSubletteCountyBoardofCountyCommissioners,2015.3ibid

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liveinPinedale(25percent),Marbleton(12percent)andBigPiney(6percent).4Inadditiontoitspermanentresidents,SubletteCountyhoststransientworkerswhocometotheareaforemployment,primarilyintheoilandgasindustry.Asmanyas2,000non‐residentworkers(primarilymen)areinthecountyatanygiventime,dependingonthelevelofgasfieldactivity.5SeveralhighwayspassthroughSubletteCounty,includingUS191,whichrunsnorth‐souththroughPinedaleenroutetoGrandTetonsNationalPark,andUS189,whichtakestrafficthroughBigPiney,MarbletonandDaniel.Accordingtothecounty,trafficincreasedby60percentormorebetween1995and2005everywhereinSubletteCounty,exceptfortheRimonHighway189/191,whichwasupabout20percent.Bigtrucktrafficalsoshowedsignificantincreasesinandaroundallthetowns,aswellasonHighway351,andUS191betweenSandDrawandFarson.Notsurprisingly,trafficaccidentsalsoincreasedinSubletteCountyduringthistime.6

EconomySubletteCountyhasaboom‐busteconomydueinlargeparttoitsmineralresources,mostnotablytheJonahandPinedaleAnticlinenaturalgasfields.Themostrecentboombeganabout1999‐2000andfueledjobs,growthandinflationforabouteightyears.Itpumpedlargeamountsofmoneyintothelocaleconomythatallowedresidentstobuildnewschools

                                                       4Sublettewyo.com5ibid6ibid

Page 1 of 1

9/21/2009http://sublette-se.org/images/accidentws2.JPG

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andoutfitclassroomswithnewcomputers.7Itdrovetheconstructionofnewhomes,hotelsandrestaurants.Duringtheboom,wageswerehighandunemploymentwaslow.TheboompeakedinOctober2008withanall‐timehighof67naturalgasrigsinoperation.Lessthanayearlater,however,inMay2009,thenumberofdrillingrigsinthecountyhaddroppedto30.8Thesharpdecreasewascausedbya70percentdeclineinnaturalgaspricesbroughtonbyweakeneddemandinthefaceofaglobaleconomicdownturn.Thedeclineinnaturalgasproductionhascontinuedinrecentyears.BakerHughes,whichtracksrotaryrigsbystate,reportsthatasofApril2016,onlyninerigsareoperatingintheentirestateofWyoming,comparedwith25oneyearearlier.9People

SubletteCountyishometosome10,000permanentresidents,accordingtotheUSCensusBureau.Thisnumberrepresentsanincreaseof68percentinlessthanadecade,whichismorethanfourtimesthepopulationgrowthrateforthestateandsixtimesthegrowthratefortheUS.10Thereasonfortheincreaseislargelyattributabletothenaturalgasindustry.

Accordingtothecounty,thenumberofactivedrillingrigsinSubletteCountyhashadadirectandimmediateeffectontheworkforcepopulation.Atanygiventime,eachdrillingrigrequiresadirectworkforceofabout22people,thevastmajorityofwhomarenon‐residentsofthearea.Whentheweeklyrotationsoftheworkforcearetallied,about44differentindividualsarededicatedtoeachrig.Scoresofadditionalworkersarealsoneededtoprovidesupportandservicestotherigs.11Since2009,thecountypopulationplateauedataround10,000residents,reflectingaslowdowninenergydevelopmentinthecounty.12

Mostresidentsarewhite,employedandearnawageabovethestateaverage.The2015WyomingCountyProfilereportedmedianearningsforfull‐timemaleworkerstobe$67,390($38,517forfemales).Mostresidentsareemployedintheprivatesector,withthegas/oilandmining/quarryingindustriesaccountingforthehighestpercentageofemployeesinrecentyears.13Alongwiththeboomalsocamecrime.Thecountyreports,“SubletteCountyenjoyedamoderatetolowcrimerate,usuallybelowtheWyomingaverage.However,withtheadventofoilandgasdevelopment,crimeratesandarrestsmadewithinSubletteCountyhavesoared.”SubletteCountyhadthehighestcrimerateinthestatein2005,eclipsingthemetropolitancountiesofNatronaandLaramie.14

                                                       7TalkoftheNation,Feb.11,20138sublettewyo.com9BakerHughesmonthlyrigreportforApril201610SubletteCountyProfile:SocioeconomicsbytheSubletteCountyBoardofCountyCommissioners,August201511sublettewyo.com12ibid13SubletteCountyProfilebytheWyomingDepartmentofInformationandAdministration,2015.14Sublettewyo.com

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HealthcareinSubletteCountyUniversityofWisconsinPopulationHealthInstituteandtheRobertWoodJohnsonFoundationeachyearpublishhealthrankingsthatshedlightonthehealthandwellnessofresidentpopulationsbycountythroughouttheUnitedStates.TheannualCountyHealthRankingsmeasurevitalhealthfactors,includinghighschoolgraduationrates,obesity,smoking,unemployment,accesstohealthyfoods,thequalityofairandwater,income,andteenbirthsinnearlyeverycountyinAmerica.Expertscompiletherankingsusingcounty‐levelmeasuresfromavarietyofnationaldatasources.

The2015CountyHealthRankingsreportsuggeststhatthehealthofSubletteCountyresidentsisverygoodcomparedtotherestofthestate.Fewerthan15percentofadultresidentssmoke,comparedto20percentstatewide.Adultobesityis21percent,comparedto27percentstatewide.Preventivecaresuchasmammographyanddiabetesscreeningalsorankshigh.TheonlyfactorsinwhichSubletteCountyscoredpoorlyarealcohol‐impaireddrivingdeaths,longcommutesandpoorqualityofdrinkingwater.15SubletteCountyHealthcareResourcesSubletteCountyresidentsobtainbasicmedicalcareattwoareaclinics,oneinPinedaleandtheotherinBigPiney/Marbleton.BothareoverseenandoperatedbySubletteCountyRuralHealthCareDistrict,acountywideelectedboardoffivenon‐partisanmembers.ThehealthcaredistricttookoveroperationoftheMarbletonclinicinMay2005andthePinedaleclinicinJuly2006.Bothclinicshavebeenrebuiltinrecentyearsusingcountyfunds(Pinedalein2007,Marbletonin2009).Thereisnohospitalinthecounty;however,discussionsareongoingregardingconvertingthePinedaleclinictoaCriticalAccessHospital(CAH).ThisconversionwouldhaveanimpactonEMS.Out‐of‐CountyHealthcareResourcesPatientsthatrequiremoreacutecarethanthatwhichcanbeprovidedinSubletteCountyaretransportedbygroundorairambulancetoSt.John’sMedicalCenterinJackson(76miles);EasternIdahoRegionalMedicalCenter,aLevelIITraumaCenter(158miles);MemorialHospitalinRockSprings(103miles);SouthLincolnMedicalCenter,aCriticalAccessHospitalinKemmerer(56miles);andtothehospitalatUniversityofUtah,aLevelOneTraumaCenter,inSaltLakeCity(250miles).                                                       15 CountyHealthRankings,2016 

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FederallyDesignatedTraumaCentersinWyoming

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III. Overview of the EMS System in Sublette County  EmergencymedicalcareinSubletteCountyincludesa911emergencymedicalcallsystem,emergencymedicaldispatch,firstresponse,groundambulance,airmedicaltransport,medicaloversightandqualityassurance.ThesystemworksthroughthecoordinatedeffortsofavarietyofagenciesthatincludesSubletteCountyRuralHealthCareDistrict,SubletteCountyEMS,SubletteCountySheriff'sofficeand911CommunicationsCenter,SubletteCountyUnifiedFire,WyomingHighwayPatrol,TipTopSearchandRescue,SubletteCountyEmergencyManagement,andavarietyofout‐of‐countyairmedicalservices.Althoughthecountyhastwomodernhealthcareclinicsthatoftenoperatelikestand‐aloneemergencyrooms,thereisnohospitalinSubletteCounty.ThenumberofrequestsforemergencymedicalresponseinSubletteCountyisunknown,ascountyEMSofficialsdisagreewiththewayinwhichdataisreportedtothestateEMSdataregistry(WATRS).16SafeTechSolutionsestimatestotalcallvolumeinSubletteCountytobeabout600annually,basedonareported491billablepatienttransportsin2015(transportstypicallyoccuron80percentofcalls).Requestsforserviceappeartobedownfrompreviousyears.Volumeinpastyearswasreportedlyashighas766(2011).2015EMSVolume(estimated) Groundambulanceresponses:589 Airmedicaltransports:unknown(noverifiabledatasourceavailable) Searchandrescuerequests:18‐24

Communications&DispatchCallsforout‐of‐hospitalemergencymedicalcarearereceivedbySubletteCountySheriff'sOffice911CommunicationsCenter.TheCommunicationsCenteranswersabout10,000callsperyear.Ofthese,fewerthan600requireEMSresponse.Thecenterismodernandup‐to‐date,withanewCADsystem,CRTradiosystem,andhasAVLmonitoringcapability.ThecenterisstaffedbydispatcherstrainedinEmergencyMedicalDispatchandpreparedtoprovidepre‐arrivalinstructions.EMSandtheCommunicationsCenterhaverecentlyaddedActive911capabilities.

                                                       16 ItisdifficulttoassessSubletteCountyEMS’scallvolumebecauseofhowdataiscollected.In2015WATRS(thestateEMSdatacollectionsystem)reports816totalcalls.SubletteCountyEMSbelievesthisnumberisunreliableduetosomeresponsesbeingenteredintoWATRSmultipletimes.Forexample,apatientwhoistransportedfromhometothehealthcareclinicandthenfromtheclinictoahospital,suchasinJackson,wouldbeenteredintoWATRStwice,butwouldonlyaccountforonebillabletransport.Themostreliabledataavailablewasthebillingdepartment’sdatafortotalbilledtransportsduringagivenperiod.SafeTechSolutionsincreasedthisnumberby20percenttoaccountforresponsesinwhichapatientwasnottransported(the20percentnon‐transportnumberiscommonacrossthenation). 

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CallsforemergencymedicalassistancearetonedoutsimultaneouslytofirstrespondersandSubletteCountyEMS.TherearebaseradiosintwoEMSstations,locatedinBigPiney/MarbletonandPinedale.Respondersusein‐vehicleandhandheldradiosaswellascellphonestostayincontactduringcalls.Respondersreportmoderatelygoodreceptionthroughoutthecounty,butoccasionallyareinlocationswherethereisnoreception.SubletteCountyEMSisdispatchedviaradiosystemandpagers.ThesystemispartofWYOLINK,thestatewidedigitaltrunkedVHFP‐25compliantpublicsafetycommunicationssystemdesignedtocoordinateandintegratecommunicationsamongstate,localandfederalpublicsafetyagencies.Communicationtechnologybetweenthedispatchcenterandambulancecrewsappearssufficient,withnoproblemsreported.ThereisnodirectcosttoSubletteCountyEMSforthedispatchservice.Thedispatchandcommunicationsystemisfundedthroughacombinationof911surchargedollarsandresourcesfromthecountygeneralfund.FirstResponse&Co‐ResponseFirstresponseinSubletteCountyisprovidedbyavarietyofagencies,includingSubletteCountySheriff’sDepartment,WyomingStatePatrol,SubletteCountyUnifiedFire,andTipTopSearchandRescue.Sheriff’sdeputiesco‐respondwithSubletteCountyEMStoamajorityof911emergencymedicalcalls.SubletteCountyUnifiedFireDepartmentco‐respondswithEMSintheareasofBondurantandKendallValley.Somepart‐time,off‐dutyEMTsalsorespondasvolunteerfirstresponders.SubletteCountySheriff’sDepartmenthas55swornofficersandanadditional15employeeswhoprovidecountywidelawenforcement,operatethe911CommunicationsCenterandjail,andoverseethevolunteersearchandrescueprogram.SubletteCountyUnifiedFireisavolunteerdepartmentlocatedinsixfirestationsscatteredacrossSubletteCounty.Thedepartmentisaconsolidationofsixdepartmentsthatwerebroughttogetherin2014.Itisintheprocessofcreatingaunifieddepartmentandcultureundertheleadershipofafull‐timefirechiefandfull‐timeadministrativeassistant.Thedepartmenthasapproximately110volunteerfirefightersandanannualbudgetofapproximately$2.4million.Thedepartmentexpectssignificantbudgetreductionsin2017‐18becauseofalowertaxbaseinashrinkingeconomy.SubletteCounty’sremotetopographyoftenmakesitnecessaryfordispatchtosendsearch‐and‐rescueteamsonEMScalls.SearchandrescueisprovidedbyTipTopSearchandRescue,aPinedale‐basedvolunteer,non‐profitorganizationofapproximately40memberswhoreportthattheyrespondtooneortwocallspermonthyear‐round.TheorganizationoperatesunderSubletteCountySheriffDepartmentandreceivesfundingfromtheSubletteCountyCommission,StateofWyoming,andprivatedonations.Theorganizationrespondstohighanglerescues,waterrescues,icerescues,avalanches,missingandoverduepersons,medicalevacuationsandbodyrecoveries.

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Firstresponders,EMSrespondersandtheCommunicationCenterreporthavingrespectfulworkingrelationshipswitheachother.911Response&MedicalTransportEmergencymedicalresponseisprovidedbySubletteCountyEMS,anambulanceserviceownedandoperatedbySubletteCountyRuralHealthCareDistrict.ItwasformedinJanuary2006fromthemergeroftwocombinationEMSagencies:PinedaleEMSandBigPiney/MarbletonEMS.SubletteCountyEMSoperatesoutoftwoEMSstations,oneinBigPiney/MarbletonandtheotherinPinedale.InthePinedalestation,anALSunitisstaffed24/7,withtheavailabilityofasecondunitstaffedbytheDirectorandsupervisingparamedic.InBigPiney/Marbleton,anALSunitisstaffed24/7.Staffingismainlywithpaidemployees,withfourvolunteersoccasionallyfillinginwhenneededforbackup.Duringsummermonths,whentourisminthecountyisatitspeak,anadditionalambulanceisstaffedinPinedale.Whileambulancesarestationedabout35milesapart,SubletteCountyEMSusesadynamicdeploymentsystemtoensurethatambulancesarebestpositionedforrapidresponse.Forexample,whenbothambulancesinPinedaleareoncalls,theBigPiney/MarbletonambulancemovestoDaniel.WhenanambulancegoesoutonacallinBigPiney/Marbleton,thePinedaleambulancemovestoDaniel.Thissystemallowsforshorterresponsetimesoveralargeservicearea.SubletteCountyEMSreportsenroutetimeof2.2minutesandanaverageon‐scenetimeunder15minutes.Occasionally,anon‐transportingquickresponseunitstaffedbyaparamedicfromPinedaleisusedtorespondandbegintransportwhileawaitingambulanceresponse.EMSrespondersprovideanadvancedlevelofserviceandtransportpatientseithertothehealthcaredistrictclinicsinPinedaleorBigPiney/Marbletonortoout‐of‐countyhospitals.Out‐of‐countymutualaidisrarelyused,butisinplacefromsurroundingcountiesandavailableonanas‐neededbasis.BecauseofthelongdistancetothetraumacenterinSaltLakeCity(upto10hoursround‐trip),SubletteCountyEMSmaypassoffpatientstoGoldCrossambulancemid‐route,inwhatisknownasapatientintercept.Inadditionto911responseandtransport,SubletteCountyEMSparticipatesinavarietyofcommunityoutreachactivities,including:

FirstaidandCPRclasses; Standbysforfootballgames,rodeos,etc.; Servingfoodatlocalnursinghome(whileonduty); Deliveringfoodbags; Supportingcommunityevents,suchasbreastcancerwalk;and EmergencyMedicalResponderandEmergencyMedicalTechnicianBasiccourses.

Inaddition,becauseSubletteCountyEMSispartofthehealthcaredistrictandbecauseambulancestationsarelocatednexttohealthcaredistrictclinics,on‐dutyEMSpersonnel

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maybesummonedbytheCommunicationsCentertomeetpatientsattheclinicdoorsafterhours,opentheclinic,andbegintotriageandcareforpatientswhilewaitingforanurseandphysiciantorespond.AirMedicalServiceAvarietyofout‐of‐countyhelicopterflightservices(AirIdahoRescue,ClassicAirMedical,GuardianFlight,LifeFlightWyoming,LifeFlightNetwork)areavailablewhenthegroundambulancecreworclinicstaffrequeststhem.TherearenoairmedicalresourcesbasedinSubletteCounty,buthelicopterandfixedwingservicesareavailablefromIdahoFalls,LanderandotherlocationsinWyoming,ColoradoandUtah.AirambulancesarenotdispatchedthroughtheSherriff’sDepartment;rather,ambulancepersonnelcontactthemdirectlyusingcellphones.ThetotalnumberofairmedicaltransportsfromSubletteCountyeachyearisnotknown;however,ambulancepersonnelreportapproximately75airmedicaltransportsannuallyfromSubletteCountyhealthcareclinics.EMSEducationSubletteCountyEMSprovidesfirstaid,CPR,firstresponderandEMTtraining.Italsoprovidesongoingstafftrainingandcontinuingmedicaleducation.Therearenoparamedicprogramswithinthecounty.EMSSystemOversight&PlanningThereisnoformalEMSsystemoversightinSubletteCounty;however,anadvisorygroupcalledtheSubletteCountyEmergencyServicesGroupmeetsregularlytodiscussemergencyplanning,challenges,interoperability,bigeventplanning,needs,grantrequestsandagroupapproachtosolutions.Thegroupiscomprisedofthecountyemergencymanager,EMS,Sheriff’sDepartment,searchandrescue,HighwayPatrol,mayors,publichealth,industry/mining,andschools,withoccasionalrepresentationfromcitizens,theparkandforestservices,homelandsecurityandotherstakeholdersasneeded.

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IV. Description of Sublette County EMS  OrganizationalOwnership&StructureSubletteCountyEMSisadepartmentofSubletteCountyRuralHealthCareDistrict,acountytaxingdistrict.SubletteCountyRuralHealthCareDistrictwasestablishedin1987followingthedissolutionoftheSubletteCountyMemorialHospitalDistrict.ThedistrictisoverseenbyaBoardofTrusteeswhoareelectedbycountyresidents.Thetrusteeshireahealthcareadministratorwhoservesaschiefexecutiveandoverseestheoperationsoftheservicesprovidedbythedistrict.Servicesincludetheoperationoftwoclinicswithmedicalstaffs,nursingservices,radiologyservices,laboratoryservicesandemergencymedicalservices.Thedistrictoperatesindependentlyofcountyandmunicipalgovernment,butusespropertyandbuildingsownedbythecounty.Theclinicisunabletomakeimprovementstothesebuildingswithoutconsentofcountycommissioners.EMSfunctionsasadepartmentofthehealthcaredistrict.Thedirectoroftheambulanceserviceishiredbythehealthcareadministratorandreportstotheadministrator.ThecurrentorganizationalchartshowstheEMSdirectorreportingdirectlytotheEMSmedicaldirector,however,inpractice,theEMSdirectorreportstotheadministratoronoperationalandfinancialissuesandtotheEMSmedicaldirectoronclinicalissues.TheEMSdirectorhasanassistantwhofunctionsintheroleofasupervisingparamedic.

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WorkforceSubletteCountyEMSemploys17full‐timeand9part‐timepersonnel.Allareactive.Fourofthepart‐timestaffareunpaidvolunteers–remnantsofatimewhenallemployeesdonatedtheirtime.Theagespanoftheworkforceisbetween25and61,withanaverageageof38.Fivefieldpersonnelareparamedics,15areAEMTs,and6areEMSbasics.EmployeesarehiredandevaluatedbytheEMSdirector.EMSstaffwork48hoursonand96hoursoff.Thereisconsiderableschedulingflexibility,andemployeesareabletoschedulesignificantstretchesoftimeoff.Whenoff‐duty,someofthestaffmakethemselvesavailabletobecalledinforback‐up.Employeeshaveapayandbenefitpackagethroughthehealthcaredistrictthatincludeshealthanddentalinsurance.Currenthourlypayratesare:

EMT‐Basic:$10.50 Intermediate/AdvancedEMT:$12.20 Paramedic:$15.60

Onthesurface,theseratesappearlowcomparedtonationalaveragesforEMSorganizationsofsimilarsizeservingruralcommunities.However,actualtake‐homepayissignificantlyhigherduetoscheduledandunscheduledovertime.Scheduledovertimecanaddseveralmoredollarsperhour.Anaccurateevaluationofcompensationincludesanevaluationofannualcompensationdividedbyhoursworked.Facilities,Vehicles&EquipmentSubletteCountyEMSoperatesoutoftwospaciousEMSstationsthatareownedbySubletteCountyandrentedtothehealthcaredistrictforthecostofupkeep(approximately$100,000peryear).Bothfacilitiesaremodernandcomfortable,withlargevehiclebays,officespace,ampletrainingrooms,dayroomswithkitchensandlivingareas,andsleeprooms.FourvehiclesaregaragedinPinedale,threeinBigPiney/Marbleton.Ambulancesavailablefor911responseinclude:

Unit15,firstoutinPinedale:2012FordF‐450madebyOsagewith48,789miles,StrykerPowerliftcot,ZollX‐seriesMonitorwiththeabilitytotransmit12leadECG,LucasDevice,ePCR,modernequipment,ingoodorder,andwellmaintained;

Unit129,secondoutinPinedale:2007FordF‐450madebyLifelinewith121,894miles,StrykerPowerliftcot,ZollX‐seriesMonitorwiththeabilitytotransmit12leadECG,ePCR,modernequipment,ingoodorder,andwellmaintained;

UnitMS14,thirdoutinPinedale:2001FordF‐350madebyLifelinewith139,000miles,StrykerPowerliftcot,ZollE‐seriesMonitor,ePCR,equipmentingoodorder,andwellmaintained;

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UnitEMS1,EchoUnit(AdvancedLifeSupportRapidResponseVehicle)inPinedale:2012ChevyTahoewith39,00miles,ZollX‐seriesMonitorwiththeabilitytotransmit12leadECG,LucasDevice,Autovent,Minimedpump,ALSsupplies,Kingvision,ePCR,modernequipment,ingoodorder,andwellmaintained;

UnitMS140,firstoutinMarbleton:2012Dodge4500madebyOsagewith49,000miles,StrykerPowerliftcot,ZollX‐seriesMonitorwiththeabilitytotransmit12leadECG,LucasDevice,ePCR,modernequipment,ingoodorder,andwellmaintained;

UnitMS256,secondoutinMarbleton:2008FordF‐450madebyLifelinewith70,000miles,StrykerPowerliftcot,ZollX‐seriesMonitorwiththeabilitytotransmit12leadECG,ePCR,modernequipment,ingoodorder,andwellmaintained;and

UnitMS141,thirdoutinMarbleton:2005FordF‐350madebyOsagewith101,000miles,StrykerPowerliftcot,ZollE‐seriesMonitor,ePCR,Equipmentingoodorder,andwellmaintained.

Allmedicalequipmentisuptodateandappropriateforthelevelofcareprovidedandthedemandsoftheservicearea.MedicalOversight&QualityAssuranceSubletteCountyEMShasprogressivepatientcareprotocols,internalqualityassuranceandengagedmedicaldirection.Afull‐timeparamedicactsastheQA/QIofficerandreviewsallrunreports.Patientcarereportsoncomplicatedand/orhighacuitycallsareforwardedtothemedicaldirectorforreview.Providerdocumentationiscontinuouslyevaluatedandsupportedwithproviderfeedbackandtraining.Thedepartmentparticipatesinregularcasereviewswithitsmedicaldirectorandclinictraumacoordinator.PatientcarereportdataisconsistentsubmittedtoWATRS.TheSubletteCountyMedicalDirectorisresponsibleforensuringfieldprovidershaveappropriatepatientcareprotocols,areclinicallycompetent,andadequatelysupportedwithclinicalcasereviews,continuingeducationandskillmaintenance.HekeepsupwithclinicaldevelopmentsandseekstoensureSubletteCountyEMSisdeliveringbestpractices.Hisinvolvementintheclinic’semergencyservicesallowsfrequentinteractionwithfieldcrews.Finance&FundingSubletteCountyEMSisfundedthroughbillingforpatientcare,taxrevenuereceivedbySubletteCountyRuralHealthCareDistrict,andlabordonatedbyvolunteers.SubletteCountyRuralHealthCareDistrictisfundedthroughbillingforpatientservicesandataxof2millsthatisleviedeachyearbythecounty.HealthcarefundsalsoaresecuredbytheRuralHealthFoundation(RHF),a501(c)(3)nonprofitcorporation.ItiscloselyaffiliatedwiththeSubletteCountyRuralHealthCareDistrictbutisseparatelygoverned

  19

andmanaged.FundsraisedbytheRHFareusedforprojectsthatimprovehealthcarethroughoutthecounty.DonationsmadetotheRHFaretaxdeductibleasallowableundercurrentIRStaxcodes.Aspartofhealthcaredistrict,SubletteCountyEMShasadepartmentalbudgetandtracksEMS‐specificrevenuesandexpenses.In2015,itreportedtotalrevenuesof$513,654receivedfrompatientbilling.Duringthesametimeperiod,itreportedtotalexpensesof$1.9million,resultinginanetlossof$1.4million.Thebillingprocessincludesthefollowingsteps:Patientcarereports(PCR)arereadandcodedbythebillingdepartment;anyquestionsaboutthePCRsarereturnedtoEMSstaffforclarificationsandcorrections;aclaimiselectronicallysubmittedthroughaclearinghouse,whenallowed.ExplanationofBenefits(EOBs)arereturnedinthesamemanner.Statementsaresenttopatientsevery28days.Paymentplansforunpaidbillsareaccepted.Internalcollectionprocessesareenacted,andwhenapplicable,anoutsidecollectionagencyused.Billingratescomparewithnationalaveragesasfollows:

BillingLevels

SubletteCountyEMS

RatesNationalAverages

Non‐emergencytransportation(WC) $25 $17Mileage $22/mile $30ALSnon‐emergency $662   

ALSemergency $1,048 $2,500‐$3,500BLSnon‐emergency $551   

BLSemergency $882 $1,000‐$2,000ALS2emergency $1,517 $3,000‐$4,000ALStreatmentwithnotransport $200 ALStreatmentwithnotransport $100

AmbulanceStandby $50/hour $200BLS/$400ALS

A0434SpecializedCriticalTransport NoUse $3,500‐$4,500

  20

Totalbillabletransportsbyyearareasfollows:

TotalBillableTransports,byTypeofTransportYear‐to‐Year17

   2011 2012 2013 2014  2015 

Total Ambulance Responses (estimated)  766 658 580 582  589 

Total Billed Ambulance Transports  638 548 483 485  491 

A0426, ALS 1 non‐emergency  2 1 1 96  173 

A0427, ALS 1 emergency  422 342 255 182  154 

A0428, BLS non‐emergency  20 6 10 92  67 

A0429, BLS emergency  151 170 195 94  66 

A0433, ALS 2  43 29 22 21  31 

A0998, Response and Treatment, No transport        12  30 

Ambulance Standbys  27.5 48.3 32.2 39.5    

Ambulanceresponsesversusbilledambulancetransportsbyyearareasfollows:

                                                       17 Accuratelyassessingvolumeremainsproblematic.SeesectiononEMScallvolumeabove. 

0

100

200

300

400

500

600

700

800

2011 2012 2013 2014 2015

Total Ambulance Responses(estimated)

Total Billed AmbulanceTransports

  21

IV. Key Observations 1.EMSisavitalandessentialelementofhealthcareandqualityoflifeinSubletteCounty.Geography,climate,distancestomedicalresources,highlevelsoftrauma,andlimitedresourcescombinetomakeEMSavitalserviceinSubletteCounty.Informantsviewtheavailabilityofambulancetransporttodefinitivemedicalcareasveryimportanttotheirsenseofsecurityandwell‐being.Intheabsenceofalocalhospitalandreadilyaccessibleadvancedmedicalspecialties,informantsdeemlocalEMSresourcesasessentialtolifeandsafetyissues.SomeinformantsreportviewingEMSasthemostessentialpartofthelocalhealthcaresystem.2.Asoperatingtoday,SubletteCountyEMSisnotsustainable.ThecurrentoperatingbudgetandoperationalstrategiesforSubletteCountyEMSappeartobebasedonfinancialandoperationalassumptionsmadeduringalocaleconomicboom.AnticipateddeclinesintaxrevenuesandotherfinancialdemandsonthehealthcaredistrictsuggestthatSubletteCountyEMSisnotsustainableasoperatingtoday.Thecurrentgapbetweenoperatingexpensesandtransportrevenuesforcesthedepartmenttorelyona$1.4millionsubsidythatislikelytonotbeavailableinthenearfuture.Withoutreducingexpensesorincreasingrevenues,thecurrentEMSoperationsarenotsustainable.

3.SubletteCountyEMSpossessesmanyelementsofaprogressiveandsustainableruralEMSsystem.Creatingasustainable,highquality,ruralEMSsystemintoday’smarketdemandsleadership,vision,operationalandfinancialefficiency,communitysupportandprogressivemedicaldirection.SubletteCountyEMShasmanyoftheseelementsinplace.3A.BoththehealthcaredistrictandEMSdepartmenthavecapableleaders.Theexecutive

$0.00

$500,000.00

$1,000,000.00

$1,500,000.00

$2,000,000.00

$2,500,000.00

$3,000,000.00

$3,500,000.00

2013 2014 2015

Expenses Vs. Patient Billing Revenue

Total Expenses

Total Revenues

  22

leadershipoftheSubletteCountyRuralHealthCareDistricthasdemonstratedclearleadershipinseekingoutthisassessment,endeavoringtounderstandruralout‐of‐hospitalemergencymedicalservices,developinganappropriateplaceforEMSindistrictplanning,andchoosingaqualifiedEMSdirectorwhoinspirespeopletofollowhim.3B.TheEMSDirectorhasgoodbusinessandpeople‐managementskills.TheEMSDirectorhasasubstantivebackgroundinbusinessdevelopmentandpeople‐managementandiscreatingaculturethatemployeesvalue.Heiscurrentlymanagingasignificantbudgetcontractionbyfindingefficiencies,isopen‐minded,andconstantlyseekingwaystoimprovethesystem.Employeesdescribehimas“oneofthebestthingsthathashappenedtoSubletteCountyEMS.”3C.TheEMSsystemisimplementingdynamicdeploymentstrategies.SubletteCountyEMSmovesitsambulancestostrategicstaginglocationswhenresourcesaredepleted.Thissystemofdynamicdeploymentrequiresmonitoringthesystem’sstatusandproactivelymovingresources(sometimestothediscomfortofemployees).Dynamicdeploymentisabestpracticestrategythatmovesambulanceassetswithinageographicareatoprovidethebestpossibleresponsetimeswhileminimizingfixedcosts.Suchforward‐thinkingandpracticeisrareinruralEMSsystems.3D.TheEMSsystemprovidesahighlevelofqualityclinicalcare.TheclinicalcareprovidedbySubletteCountyEMSmatchesbestpracticesinruralareasaroundthenationandisclearlyanorganizationalpriority.Theserviceprovidesadvancedlevelcareandisappropriatelystaffed.TheMedicalDirectorisappropriatelyqualified,preparedandengagedandisalwaysseekingwaystoensurethatSubletteCountyEMSisontheleadingedgeindeliveringhigh‐quality,ruralemergencymedicalcare.Informantswiththecommunity,clinicandreceivinghospitalsreportnoconcernsaboutclinicalcareprovidedbySubletteCountyEMS.

3E.EMSisadequatelyintegratedintothelocalhealthcaresystem.TensionbetweenEMSandclinical/hospitalstaffoftenoccurswhenEMSispartofahospitalorhealthcaredistrict.ThistensionoftenisduetodifferencesbetweenhowEMSoperatescomparedtoclinicsandhospitals.IssuesthatcreatetensionareEMScrews’downtimebetweencalls,theprovisionofuniforms,andanexpectationthatEMScrewsbeusedtosupplementclinicorhospitalstaff.ThereisasurprisingabsenceofthesetensionsinSubletteCounty.TheclinicstaffclearlyembracestheEMSdepartmentandtheuniquenessofhowEMSoperates.ThedistricthassucceededinintegratingEMSinwaysthatstrengthenbothEMSandthedistrict.EMSiscalledupontoassistwithpatientcareinamannerthatstrengthensEMSclinicalskillsanddeepenstherelationshipbetweenEMSandclinicpersonnel.EMScrewsprovideavitalandcost‐savingafter‐hourfunctionofopeningtheclinicforpatients,beginningpatientcareandsummoningnursing/medicalstaff.TheintegrationdescribedabovepavesthewayforfurtherintegrationusingCommunityParamedicineandMobileIntegratedHealthcare.(SeeAppendixA).

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3F.SubletteCountyEMShasaknowledgeableandcompetentbillingdepartment.WhenevaluatinganEMSagency’sbillingcapacity,SafeTechSolutionsconsidersthebillingstaff’stechnicalknowledgeofEMS‐specificbilling,theuseandunderstandingofkeyreimbursementperformancemeasures,thetimeavailabletomanageEMSclaims,andwhetherEMSreimbursementisseenasaprioritycomparedtootherclaimswithintheorganizations.SubletteCountyEMSbillingstaffisknowledgeableaboutEMSbilling,includingareassuchasHCPCcodes,originanddestinationmodifiers,andtheneedtobillMedicareforadenialpriortobillingabeneficiaryforanon‐coveredservice.Thebillingstaffisabletoquicklyandeasilyprovidedataonkeybillingperformancemeasures,suchasA/Rdays,A/R,payermix,andbillablecallsbyoriginanddestination.Itisunlikelythatoutsourcingbillingwouldbringadditionalrevenuesintothesystem.Outsourcingcouldcomplicatefinancialmanagement;impedethewayinwhichbillingpracticesworkwithintheorganizationalmission,vision,andvalues;andhindercustomerservice.4.SubletteCountyEMSfacesmajorchallengesassociatedwiththelocaleconomy,aswellaswithitspositionwithinthehealthcaredistrictanditslackofaclearvisionandstrategicplan.MajorchallengesfacingSubletteCountyEMSarethelocaleconomy,howEMSispositionedwithinSubletteCountyRuralHealthCareDistrict,andtheabsenceofaclearvisionandstrategicplanforEMS.Specifically,thesechallengesare:4A.SubletteCountyanticipatessharpreductionsintaxrevenues.Duringthepastdecade,SubletteCountyEMShasoperatedwithoutmuchconcernaboutoperationalcosts.Thelocaleconomyprovidedampleresourcesthroughtherevenuescollectedbythehealthcaredistrictthat,inturn,subsidizedtheEMSsystemtothetuneofmorethan$1millionannually.18Asignificantdownturninthelocalmineralextraction‐basedeconomyisthreateningtheresourcesavailabletosubsidizeEMSoperations.

InformantsfromSubletteCountyandthehealthcaredistrictreportedanexpectationofsignificantdeclinesinrevenuesin2016andbeyond.EffectiveMay21,2016,thehealthcaredistrictbeganinitiativesto“rightsize”healthcareservicesprovidedinSubletteCounty.Theseinitiativescomeontheheelsofananticipated$3.5millionreductionoftaxrevenuethiscomingbudgetyear.Itisalsoanticipatedthatthedistrictwillfaceanadditional$1.75millionreductionforthe2017budget.

Reductionsinexpendituresincludeadjustmentstoemployeebenefits,positioneliminationperattrition,paywageadjustmentsperattritionandchangesofpurchasinggroupfor                                                       18 Asubsidyistherevenuesneededtomakeupthedifferencebetweenoperationalcostsandwhatiscollectedfrombillingforservices. 

  24

suppliesandequipment.SaturdayclinichoursattheBigPiney/MarbletonandPinedaleClinicsweresuspendedindefinitely.

4B.EMSwillbeaffectedbychangeswithinthehealthcaredistrict.Aspartofitsefforttoincreaseservicesandrevenue,SubletteCountyhealthcaredistricthasbeenaggressivelyseekingCriticalAccessHospital(CAH)designationforitsPinedaleclinic.CAHdesignationhasthepotentialtogreatlyenhancebillingrevenuethroughcost‐basedreimbursementforcurrentservices,aswellaspermitadditionalservicessuchasin‐patientcare,swingbedcareandobservationcare.ThischangeofdesignationcouldhavebothpositiveandnegativeimplicationsforEMS.Currently,about30percentofpatienttransferstoout‐of‐countyemergencydepartmentswouldbeeligibleforcareataCAH,meaningpatientswouldnotbetransferred,andasaresult,transferrevenuewoulddiminish.However,CAHstatusalsohasthepotentialtoincreaseEMSrevenuebecauseambulancetransportstotheCAHwouldbecomeeligibleforreimbursement(whereastransportstotheclinicarenot).AmbulanceservicesthatarepartofaCAHthatmeetthe35‐milerulealsoareeligibleforcost‐basedreimbursement,unlikethemajorityofambulanceserviceswhicharereimbursedunderaMedicareFeeschedule.Thehealthcaredistrictiscurrentlyawaitinga“greenlight”fromcountycommissionerstomakerequiredphysicalchangestotheclinicstructurestomeethospitallifesafetycodesandregulations.WhetherCAHdesignationwillbesuccessfulisunknown.Acrossthenation,manyCAHsfacesignificantsustainabilityissues.Informantsareconcernedthatdistricttime,attention,focusandresourceswillbeneededtomakeaSubletteCountyCAHsuccessfulandmaydivertimportantresourcesfromEMS.Asoneinformantsaid,“Ifthathospitalfails,we’llstillneedEMS.”4C.PerceptionsaboutthehealthcaredistrictmayhurtEMS.SomeinformantsreportedhavinglittleconfidenceinthehealthcaredistrictBoardofTrusteesbeingabletoadapttodeclinesintaxrevenues.Someinformantsbelievethatthedistricthasoverbuilt,growntoolarge,andisunwillingtoreduceservicestomatchdecliningrevenues.Theseperceptionsmayhaveanimpactonthelong‐termviewofEMSinSubletteCountyandtheresourcesthatitneedstocontinuetoprovideahighlevelofqualityservice.4D.SubletteCountyEMSlacksaclearvisionandstrategicplan.Localresidents,ambulancepersonnelanddistrictleadersareeasilyabletoarticulatetheday‐to‐daybenefitsofhavingahighlevelofqualityEMSinSubletteCounty.CommunityinformantsspokepassionatelyabouttheimportanceofEMSasameanstoaccessthehealthcaresystem.However,bothinformantsandEMSstaffalsoexpressedconcernaboutthefuturebecauseEMSlacksaclearvisionandstrategicplan.Asresourcesbecomescarce,findingandkeepingtherightpersonnelbecomesmoredifficult,leadersareforcedtomakedifficultdecisions,andthereisuncertaintyaboutwhatwillguideplanninganddecision‐making.Havingaclearlydefinedandeasilyunderstoodvisionandplanforthefutureprovidesleaderswithapowerfulstorywhenfightingforresources.

  25

5.SubletteCountyEMSlacksclaritywithregarditsstructure,leadership,workforce,anddatagathering.5A.Thehealthcaredistrictreportingstructureneedsclarification.ThecurrentorganizationalchartshowstheEMSdirectorreportingdirectlytotheEMSmedicaldirector.Inpractice,informantsdescribetheEMSdirectorasreportingtothehealthcaredistrictadministratorforoperationalandfinancialissuesandtotheEMSmedicaldirectorforclinicalissues.Organizationalchartsprovideclearlinesofauthorityandresponsibilities.Theycreatestructurestosupportefficiencies,synergiesandcollaborations.Operations(theambulancedepartmentleader)andclinicalcare(themedicaldirector)mustworkcloselyandhavesharedresponsibilitieswithintheambulancedepartment.However,attimes,theyhaveconflictingresponsibilities,suchasmeetingbudgetresponsibilitiesversusnewclinicalinitiatives.5B.Departmentaljobdefinitionsandreportingstructureareweak.SubletteCountyEMShasaninformalstructurethatidentifiesanambulancedirector,assistantdirector,supervisors,employeeswithassignedareasorresponsibilities(suchasQAorvehiclemaintenance),andclinicalstaff.Jobdescriptionsandkeyperformanceindicatorsforeachjobarenotup‐to‐date,nordotheyaccuratelyreflectcurrentperformance.Formalizingtitles,positions,jobdescriptionsandreportingstructureprovidesclarityandensuresallemployeeshavetheappropriateresponsibilityandempowermenttobesuccessfulwithintheirpositions.5C.ThecurrentEMSleaderdoesnothavedeepoperationalandfinancialexperienceinEMS.Whilewellliked,thecurrentEMSleaderlacksexperienceintheEMSindustry.InformantswithinandoutsideoftheorganizationreportthatthecurrentEMSdirectorisanexcellentchoicetoleadtheorganization.Heisrespectedandcreditedwithbringingafun,friendly,team‐likeculturetotheorganization.SafeTechSolutionsagrees;however,whilehehasgreatbusinessandpeople‐managementskills,heandthedepartmentcouldbenefitfromadeepeningofhisexposuretoandknowledgeofEMSleadershipandmanagementconceptsspecifictoEMSorganizations.ThisincludesEMSleadership,matchingcallvolumewithresources,schedulinginalow‐volumeagency,longtransports,matchingorganizationalresourcestoadecreasingcallvolume,andEMSemployeeengagement.5D.EMSemployeeengagementisprecarious.Whileemployeesgenerallyreportbeingcommittedtotheorganizationandpleasedwithitscurrentleadership,employeeengagementatSubletteCountyEMSnonethelessseemstenuous.Thisconclusionisrelatedtothemannerinwhichcut‐backswerehandledpriortotheleadershipofthecurrentEMSdirector,concernsaboutannualearnings,concernsaboutthelocaleconomyandthefinancialhealthofthehealthcaredistrict,perceptionsthatEMSisnotapriorityforthedistrict,concernsthatannualincomewillbereducedastheEMSdepartmentlimitsovertime,andconcernsthatthecurrentleaderwillnotstay.Employeeengagementisawayoftalkingaboutemployees’enthusiasm,commitment,

  26

loyaltyandwillingnesstodomorethanrequiredtoadvancetheorganizationalmission.Employeeengagementiskeytoorganizationalsuccess.Engagementisconnectedtoefficiency,safety,customerservice,patientcareandlong‐termsuccess.Currently,SubletteCountyEMShasnoformalmeansofmeasuringemployeeengagement.6.SubletteCountyEMSisnotoperatingefficientlynormaximizingitsrevenuefrompatientbilling,anditmayhavelittleornoincentivetodoso.6A.Thecurrentschedulingsystemisnotefficient.Thecurrentcallscheduleof48hourson/96hoursoffisdemandingonfieldpersonnelandresultsin2,496hoursofovertimeperfull‐timeemployeeperyear.Thismodelisfinanciallyunsustainableandexposestheorganizationtolargelegalrisks,suchaswageandhourcomplaintsandlitigation,andtheriskofmedicalerrors,vehiclecrashes,andlowemployeemoraleandengagement.ThecallscheduleusedbySubletteCountyEMSjeopardizestheorganization’slong‐termsurvivabilitybycreating96hoursofovertimeperweek.Inatwo‐weekpayperiod,thetypicalfull‐timeemployeeworks48hoursofstraighttimeand96hoursoftime‐and‐a‐half.Thissystemisusingthe8and80rule,inwhichovertimeispaidforanyhoursovereightinagivenday.With96hoursofovertimeperpayperiod,anemployeereceives2,496hoursofovertimeeveryyear.Thissystemresultsinemployeesreceivingmoreinovertimepaythantheydoinstraighttime(1,248hoursofstraighttime,2,496hoursofovertimepay)andanannualwageof$77,875peryearforastartingparamedic.Payrollcostswillgrowexponentiallyduetothescheduledovertime.Thelogicalresultisunsustainablegrowthinsalarydollars.

AnticipatedWageIncreasesOvertheNextFiveYears

UndertheCurrentOvertimeSystem19

                                                       19 Thecalculationusesstartingparamedicpayandassumesatotalyearlyincreaseincompensationof3percent. 

1248

2496

Straight Time vs. Over Time

Straight Time

Over Time

  27

2016 2017 2018 2019  2020 

Straight Time  $19,468.80 $20,052.86 $20,654.45 $21,274.08  $21,912.31 

Over Time  $58,406.40 $60,158.59 $61,963.35 $63,822.25  $65,736.92 

Annual Comp  $77,875.20 $80,211.46 $82,617.80 $85,096.33  $87,649.22 

Anothersignificantconcernisthepossibleeffectthat48hoursofon‐dutytimecouldhaveonemployees,suchastheriskoffatigueresultinginmedicalerrors,motorvehicleaccidents,lowengagement,poormorale,andpoorphysicalhealth.Nationally,mostorganizationsareeliminating24‐hourshiftsduetooverwhelmingresearchlinkingshiftlengthwithmedicalerrors,vehicleaccidentsandpooremployeehealth.6B.TheEMSsystemhastoomanyresourcesforitscallvolume.Thecurrentunitdeploymentmodelofthree24‐hourambulancecrewsondutyperday(fourduringsummerhours)plusasupervisorwithaccesstoanEchounitdoesnotmatchthecallvolumeoffewerthantwocallsaday.Themostreliabledataforunderstandingthecurrentcallvolumecomesfromthebillingdepartment,whichsuggeststhatSubletteCountyEMSrespondstoanestimated589callsperyear.20Thisaveragesto1.7callsaday.Becauseofalackofdata,someassumptionsneedtobemadetocalculateneededresources.Forexample,let’ssayonecallperdayresultsinapatientbeingtransportedtoalocalclinic,andthattransporttakesonehourfromstarttofinish.Asecondcallresultsinanout‐of‐countytransportthattakesatotalofsixhours.Theresultwouldsuggestthatambulancesareengagedanaverageofsevenhoursperday.Basedonthisassumption,aswellasavailabledata,itisreasonabletoassumethattwo24‐hourambulancecrewscouldeasilyprovidecoveragetoSubletteCounty,withaminimaldelayinresponsetimesoroccurrenceswhentheunitsareunavailable.21Incontrast,SubletteCountyEMScurrentlystaffsthreeambulances24hoursaday,andfourinthesummermonths.Thisstaffingmodel,coupledwiththeamountofovertimethatresultsfromit,ispartlyresponsiblefor$1.9millioninexpenses(muchofwhichgoestolabor),anda$1.4millionannualshortfall.6C.Billingratesforpatienttransportsaretoolow.SubletteCountyEMSmaybelosingrevenuebybillingatratesthatarelessthanthecostofprovidingservice.Acrudewaytocalculatetargetbillingratesistodividetotalexpensesbytotalbillabletransports.Withexpensesof$1.9millionand491billabletransports,eachcallwouldneedtoreturn$3,853tothesystemtocovertheexpenseofprovidingtheservice.                                                       20 Thisiscalculatedbyadding20percentor99responsestothereported491billablecallsin2015.A20percentno‐transportrateiscommonforU.S.EMSservices. 21 AtypicalEMSgoalistostaffforcoverageof80percentofthecallvolume.Itwouldbefinanciallyunsustainabletostafffor100percentofcallvolume(i.e.alwayshavinganambulancewaitingforthepotentialofacall). 

  28

Incontrast,SubletteCountyEMSreceives,onaverage,$913percall,resultinginalossof$2,940.95percall,basedoncurrentexpenses.Raisingratesclosertonationalaverages(seechartonPage17)couldoffsetasmuchas50percentofthecurrentexpenses.Forexample,let’ssayrateswereraisedtoananaveragechargeof$3,335pertransport.Atthecurrentrateofreturn(45percent),eachtransportwouldresultin$1,500.75,foratotalofroughly$740,000annually.TheEMSsystemmightfindadditionalrevenuebytakingall192patientscurrentlybeingtransportedbyairmedicalservicesandshiftingthemtogroundambulance,whichcouldaddanadditional$288,144totherevenue,foratotalof$1,028,000annuallyorapproximatelyone‐halfofthecurrentexpenses.ItisunlikelythatSubletteCountyEMScouldraiseitsrateshighenoughtobreakeven;however,withcostcontainmentandincreasedrevenues,itcoulddramaticallyreducetheamountofneededsubsidy.6D.EMSislosingpotentialrevenuebytransportingpatientstodistrictclinics.WhenSubletteCountyEMStransportspatientstodistrictclinicsratherthantohospitals,andthepatientsaretreatedattheclinicsandnottransferredtohospitals,SubletteCountyEMScannotcollectforitsservices.TheCentersforMedicareandMedicaidServices(CMS)doesnotallowambulanceservicestobillMedicareforambulancetransportstoalternatedestinations,suchasclinicsandphysicians’offices.Theexactnumberofpatientstransportedtoclinicseachyearisnotknown;however,SafeTechSolutionsbelievesthatitrepresentssomepotentiallostrevenue.AnambulanceservicemaybillMedicarepatients(usingtheuniqueclaimcodeA0888non‐coveredservice)fortransportstoaclinicorphysician’sofficeonceanofficialdenialofpaymentisreceivedfromMedicare;however,thereisnoindicationthatthispracticebeingdone.UseofA0888,oftenreferredtoas“billingforadenial,”wouldprovideanindicationofhowoftenthissituationoccurs.6E.EMSdoesnothaveacapitalreplacementplan.Havingadetailedcapitalreplacementplanguidesadepartmentinplanningfortheuseoflimitedcapitalfunds.Withoutalong‐termplan,resourcesoftenareallocatedtothecrisisoftheday,ordepartmentsarepittedagainsteachother,whichresultsintensionandturmoilwithintheorganization.6F.Thefrequentuseofairmedicalresourcesmaynotbeclinicallynecessaryoroperationallyefficient.SubletteCountyEMScurrentlydoesnottracktheuseofairmedicalresourcesinthecounty,nordoesithaveanairmedical‐specificprotocoltoguidefieldandclinicpersonnelintheuseofairmedicaltransport.Theuseofairmedicalresourcescanbedifficultandcomplex.Whendistancesaregreatandapatientappearsacute,airmedicaltransportappearstobeareasonablechoice.However,costs,risksandlossofgroundtransportrevenueareimportantfactorsintheairmedicalequation.AnairmedicalhelicopterbillinWyomingtodayisroughly$65,000andcouldhavea20percentco‐paytothepatientofroughly$13,000.Airmedicalresourcesareoftenoverused.22Bydeveloping

                                                       22 http://www.theatlantic.com/health/archive/2016/01/air‐ambulance‐helicopter‐cost/425061/ 

  29

guidelinesforappropriateuseandarigorouspost‐usereviewprocess,SubletteCountycanensurethatairmedicaltransportiswarranted,andthecostandrisksjustified.6G.TheongoinghealthcaredistrictsubsidyoftheEMSservicemightserveasadisincentiveforimprovedorganizationalefficiencyandrevenuemaximization.TheexpensestooperateSubletteCountyEMStodayfarexceeditsrevenues.ThepolicybythehealthcaredistricttooffsetEMSlossesusingdistrictfundsmaybeadisincentivetotheEMSsystemtoraiseitsbillingrates,takeonmorepatienttransfers,andmakeotherchangesnecessarytoachieveabalancedbudget.Withoutasignificantsubsidyfromthedistrict,SubletteCountyEMSwouldberequiredtomakesignificantadjustmentstoitsexpensesandrevenuestoremainfinanciallyviable.Whileitisnotuncommonforruralambulanceserviceswithalargegeographiccoverageareaandalowcallvolumetobesubsidized,asubsidythatconsistentlymakesupforashortfallwithoutdemandingconcomitantresponsibilitymaycreateanenvironmentinwhichattentiontofiscalresponsibilityisoverlooked.7.SubletteCountyisfailingtodoanadequatejobofcollectingdataandanalyzinginformationaboutitsEMSsystem.SubletteCountyEMSlacksreliabledataandinformationneededforanalysisandimprovement.BasicdataandespeciallyhistoricaldataaresomeofthemostimportanttoolsanEMSleadercanhave.Databecomesevenmoreimportantwhenmanagingaruralorganizationwithalargeanddiverseserviceareaandlowcallvolume.7A.SubletteCountyEMSdoesnothavebasiccalldata,andthedatathatitdoeshaveisatoddswithstate‐reporteddata.SubletteCountyEMSneedsreliableanddependabledatasourcesthatitcanminetoconductanalysesofkeyperformanceindicators,suchascalldata,peakvolumeperiods,financialperformance,medicationandequipmentutilization,etc.BasedonSafeTechSolutions’multipleattemptstoobtainreliablecalldata,theonlysourceofreliableinformationappearstobethebillingsystem.TherealsoisadiscrepancybetweendatareportedtothestateEMSdatabase(WATRS)andtheorganization’srunvolumedata(Seegraphiconpage30),resultinginaninabilitytoproperlyuseretrospectivedatatodrivestrategicdecision‐making.Calldata,suchascallsbytimeofdayanddayofweek,helpmanagerstoknowwhentodeployresources.Ascallvolumegrowsordeclines,datainformsdecisionsaboutwhentoaddresourcesorwhentotakeresourcesoutofthesystem.

  30

DataDiscrepancies

2011 2012 2013  2014 2015

WATRS Data for Total Responses  1117 976 994  859 799

Ambulance Responses (estimated from billing data)  766 658 580  582 589

Total Billed Ambulance Transports  638 548 483  485 491

7B.SubletteCountyEMSdoesnothavedefinedkeyperformanceindicators(KPIs).KPIsaremeasurablevaluesthatdemonstrateshoweffectivelyanEMSsystemisperforminginkeyobjectives.EMSorganizationsuseKPIstoevaluatetheirsuccessatreachingtargetsandmakingneededchange.7C.SubletteCountyhasnoformalorinformalprocessformeasuringEMSemployeeengagement.Employeeengagementisakeyindicatoroforganizationalperformance.Engagedemployeesdriveorganizationalsuccess.Disengagedemployeesmaydragdownothersandimpactoperationalperformance,patientcarequality,customerserviceandrecruitmentandretention(especiallyinatimeofworkforceshortages).A2013HarvardBusinessReviewAnalyticServicesreportofmorethan550executivesfoundthat71percentofexecutivesrankemployeeengagementasveryimportantinachievingsuccess.23Acrossthenation,someofthebestEMSorganizationsarefindingthatprioritizingandmeasuringemployeeengagementisaperformancemeasurethathasabigimpactonall

                                                       23 TheImpactofEmployeeEngagementonPerformance,2013,HarvardBusinessSchoolPublishing. 

0

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others.Engagementisformallymeasuredusingengagementsurveysandinformallymeasuredbypreparingleadersandsupervisorstoprioritizeengagementandrecognizeitspresenceorabsence.7D.SubletteCountyhasnoformalmeasurementofEMScustomersatisfaction.WhileSubletteCountyHealthCareDistrictdoestrackcustomersatisfactionthroughsurveys,itscustomersatisfactiondataisnotspecifictoindividualdepartments.ThegeneralityofthedatamakesitdifficulttounderstandthesuccessesandareasforgrowthintheEMSdepartment.EMSmaybeapatient’sfirstexperienceorthelastexperiencewithahealthcaresystem.Theseimpressionsoftencolortheentirepatientexperience.UnderstandingmorespecificallyhowEMSismodelingtheactionsandbehaviorsoftheorganizationwouldprovideactionablegoalsandobjectivesforthedepartment.

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V. Recommendations1.CreateavisionandplanforEMSsuccessandsustainability.Avisionisavisualizationanddescriptionofthefuturethatguidesplanninganddecision‐making.Theprocessofcreatingavisionassistsanorganizationinthinkingthroughwhereitisgoingandwhatspecificallyisneededtogetthere.AsthehealthcaredistrictpursuesCAHdesignationforitsclinic,itshouldalsocreateavisionforsustaininghighqualityEMSinthecounty.WhileaCAHwillexpandlocalmedicalcareandprovideadvantagesforpatientstabilizationandlocalmitigationofminormedicalemergencies,SubletteCountywillalwaysbereliantuponemergencymedicaltransportationtohigherlevelsofcare.AvisionforthefutureofEMSinSubletteCountyshouldincludethefollowingelements: Adescriptionofthelevel,quantityandqualityofservicesneeded,wantedand

fundable.Thevisionshouldreflectalevel,quantityandqualityofEMSserviceappropriateforalargeruralregionwithlimitedmedicalresources,longresponseandtransporttimes,andlimitationsofclimate,weatheranddistancetovariousmedicalspecialties.ThelevelofcareenvisionedwilllikelybeAdvancedLifeSupportwithsomecriticalcareandcommunityparamediccomponents.ThequantityofEMSresourcesshouldappropriatelyfitanticipatedcallvolume,andqualityshouldbeassessedandguidedbybestpractices.

PrioritizationofEMSaboveotherlocalmedicalofferings.BecauseofEMS’svitaltransportationroletoadvancedlevelsofcare,itisessentialthatEMShavepriorityinhealthcarespendinginSubletteCounty.ThevisionshouldtakeintoconsiderationtheopportunitiesandrisksofCAHdesignation,whichcouldprovideadditionalresourcestoEMS,suchastheabilitytobillwhenpatientsarebroughttotheCAH,aswellascost‐basedreimbursementforEMS.ButCAHdesignationalsocouldbecomealiabilityforEMSbybecomingthetoppriorityincommandingdistrictresources,suchastime,attentionandmoney,inboththeshort‐termandlong‐term.EMSmustremainapriorityregardlessofCAHdesignation.

ApowerfulandreassuringstorytotellaboutEMS.AvisionthatensuresEMSwillbeprioritizedindistrictplanningmayassistleadershipintellingareassuringstoryabouttheuseoflocalfinancialresources.

Maximizationoftheuseofground‐basedEMS.Inenvisioningthefuture,itisimperativethatEMSisappropriatelyusednotonlyfor911responseandtransportbutalsoforinterfacilitytransfersaswellintheemergingroleofintegratingwithandextendingaccesstohealthcarethroughcommunityparamedicine.

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2.StrengthentheEMSorganizationalstructureandleadershipteamtosupportsustainability.HavingastrongorganizationalstructureintheEMSdepartmentwillcontributetolong‐termsustainabilityandisvitaltoorganizationalperformance.SubletteCountyEMSshouldtakethefollowingactions: ClarifytheEMSreportingstructureforEMSwithinthehealthcaredistrict.Boththe

EMSdirectorandtheEMSmedicaldirectorshouldreportdirectlytothehealthcareadministrator,withdottedlinereportingbetweentheEMSdirectorandtheEMSmedicaldirector.Thisstructurecreatesanadvantageousseparationbetweenclinicalcarereportingandoperationalandfinancialreporting.

Clearlydefinetheroles,responsibilitiesandperformanceindicatorsoftheEMSleadership/managementteam.Identifytheneededteamstructureandroles(suchasdirector,assistantdirector/manager,qualitycoordinator,supervisors,trainingcoordinator,etc.).Rolesandtitlesshouldhaveclearjobdescriptionsandperformanceindicatorsthatareunderstoodbyallandusedtoguideperformance.

InvestintheEMSleadershipteam’sknowledgeofEMSoperationsandfinanceandexposuretobestpractices.SubletteCountyEMSwillbenefitfromEMSleadershiptrainingandeducation,exposuretoothersystems,andcontinuouslearningaboutbestpracticesandinnovation.LeadershipshouldbeencouragedtoattendEMSleadershipeducation,conferencesandseminars.

Ensuretheleadershipteamiscommittedtotheorganizationanditsfuture.

3.Strengthenoperationalandfinancialefficiencybynarrowingthegapbetweenexpensesandrevenues.Efficientuseofhuman,financialandmaterialresourcesiskeytolong‐termsustainability.SubletteCountyEMScouldcutitscurrentlossesinhalf,andpossiblymovethedepartmenttobreak‐evenstatusbytakingthefollowingactions: Reducethenumberofdeployedresourcestomatchanticipatedcallvolume.Basedon

bestavailabledata,SubletteCountyEMShastoomanystaffedambulancesondutyperdayandshouldreduceresourcestotwo24‐hourtransportingambulancesperday.UnitutilizationshouldbestudiedtoconsidertheadditionofanEchounittoaugmentresponsecapability.

Developandimplementanewcallschedulethatreducesovertimeandissafeandhumane.Thecurrent48on/96offscheduleshouldbemodifiedtoonethatislesstaxingonfieldpersonnelandresultsinlessovertime.SafeTechSolutionsrecommendsa36‐hourworkweekforfieldstaff.Theschedulewouldconsistofthree12‐hourshifts.Twoofthe12‐hourshiftscouldbeputtogetherforamaximumof24hoursonduty,withatleast12hoursoffbetweenshifts.Thischangemay

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requirethehiringofadditionalfieldpersonnelandwillresultinadditionalshort‐termexpenses(hiring,uniforms),butissaferinthelong‐term.Inaddition,itwillresultinlessovertime,whichwillreduceexpenses.Eliminatingscheduledovertimeshouldbeagoal,andunscheduledovertimeshouldbenomorethan10percentoftotalwages.

Raiserevenuebyincreasingbillingrates,capturinglostrevenueandensuringallpatientsaretransportedtoahospital.

Developacapitalvehiclereplacementplan.Developaschedulewithcostsforallcapitalpurchasesoverthenext10years.Usethisscheduleasamaptoplanfinanciallyandoperationallytoensurethattheorganizationhasthemostup‐to‐datephysicalassetsandfinancestopayforthoseassets.

Useairmedicalresourcesefficiently.Airmedicaluseshouldbeguidedbyclinicalandoperationalneedsanddeterminedbyastandardprotocol.Createanairmedicalprotocolbystudyingcurrentairmedicaluseanddeterminingwhetheruseismedicallynecessaryandappropriate.DeterminewhetherSubletteCountyEMSislosingrevenuebyover‐useofairmedicalresourcesversuslong‐distancegroundtransports.

4.Usedatatodrivedecisions.Thecollectionandappropriateuseofdataisessentialtoefficientsystemoperations.Decision‐makingshouldbeguidedbyreliabledataandinformation.Specifically,SubletteCountyEMSshould: Ensurethatessentialdataisreliable,complete,andconsistentwithotherdatasources,

suchasWATRSandthelocalcommunicationcenter.TheWATRSsystemprovidesmanypre‐definedandcustomreportstoanalyzesystemperformance.EnsuringthedatasubmittedtoWATRSis100percentreliableshouldbeapriority.

Developadashboardthatincludeskeyperformanceindicatorscriticalforsuccess.A

dashboardisaquickwayofmonitoringsystemperformance.ForSubletteCountyEMS,adashboardmayinclude:

o Systemstatus(howoftendeployedresourcesarebeingusedandhowoften,whenthesystemislowonresourcesandresponsetime);

o Schedulingandovertime(consistencyofscheduletolimitovertimetopredeterminedlevel);

o Clinicalquality(protocolcompliance);o Financialperformance(expenses,revenues,collectionrates)’o Airmedicaluse;ando Customersatisfaction.

Regularlymeasureemployeeengagement.Employeeengagementiskeytoensuring

thattheorganizationhasaculturethatemployeesloveandtowhichtheyare

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attracted.Engagementshouldbemeasuredthroughannualsurveysandregularconversationswithemployeesconcerningkeyengagementissues.

5.Continuetodevelophealthcareintegration

ThedistrictshouldcontinuetointegrateEMSintoitshealthcareofferings,andexploreexpandingitsuseofEMSintonon‐911serviceswiththegoalofcreatingatrulyintegratedcaremodel(seeAppendixA).

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Appendix A WhatisCommunityParamedicine?CommunityParamedicsorMobileIntegratedHealthcare(MIH)istheprovisionofhealthcareusingpatient‐centered,mobileresourcesintheout‐of‐hospitalenvironment.Itmayinclude,butisnotlimitedto,servicessuchasprovidingtelephoneadviceto9‐1‐1callersinsteadofresourcedispatch;providingcommunityparamedicinecare,chronicdiseasemanagement,preventivecareorpost‐dischargefollow‐upvisits;ortransportorreferraltoabroadspectrumofappropriatecare,notlimitedtohospitalemergencydepartments.KeycomponentsofMIHprogramsinclude:• Fullyintegrated–avitalcomponentoftheexistinghealthcaresystem,withefficient

bidirectionalsharingofpatienthealthinformation.• Collaborative–predicatedonmeetingadefinedneedinalocalcommunityarticulatedby

localstakeholdersandsupportedbyformalcommunityhealthneedsassessments.• Supplemental–enhancingexistinghealthcaresystemsorresources,andfillingthe

resourcegapswithinthelocalcommunity.• Datadriven–datacollectedandanalyzedtodevelopevidence‐basedperformance

measures,researchandbenchmarkingopportunities.• Patient‐centered–incorporatingaholisticapproachfocusedontheimprovementof

patientoutcomes.• Recognizedasthemultidisciplinarypracticeofmedicine–overseenbyengaged

physiciansandotherpractitionersinvolvedintheMIHprogram,aswellasthepatient’sprimarycarenetwork/patient‐centeredmedicalhome,usingtelemedicinetechnologywhenappropriateandfeasible.

• Teambased–integratingmultipleproviders,bothclinicalandnon‐clinical,inmeetingtheholisticneedsofpatientswhoareeitherenrolledinorreferredtoMIHprograms.

• Educationallyappropriate–includingmorespecializededucationofcommunityparamedicineandotherMIHproviders,withtheapprovalofregulatorsorlocalstakeholders.

• ConsistentwiththeInstituteforHealthcareImprovement'sIHITripleAimphilosophyofimprovingthepatientexperienceofcare;improvingthehealthofpopulations;andreducingthepercapitacostofhealthcare.

• Financiallysustainable–includingproactivediscussionandfinancialplanningwithfederalpayers,healthsystems,AccountableCareOrganizations,managedcareorganizations,PhysicianHospitalOrganizations,legislatures,andotherstakeholderstoestablishMIHprogramsandcomponentservicesasanelementoftheoverall(IHI)TripleAimapproach.

Legallycompliant–throughstrong,legislatedenablementofMIHcomponentservicesandprogramsatthefederal,stateandlocallevels.