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Res 97-259�J RES�LUTION NO. 9� � A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF FEDERAL WAY AUTHORIZING KING COUNTY TO PLACE, ON THE NOVEMBER 1997 GENERAL ELECTION BALLOT, A MEASURE REGARDING A COUNTY-WIDE BALLOT PROPOSITION FOR FUNDING EMERGENCY MEDICAL SERVICES ("EMS") PURSUANT TO RCW 84.52.069, AS AMENDED. WHEREAS, RCW 84.52.069 allows counties and certain other taxing districts, subject to voter approval, to impose an additional regular property tax of up to $.50 per thousand dollars of assessed valuation in each year for six consecutive years for the purpose of funding emergency medical services; and WHEREAS, King County is seeking voter authorization of an emergency medical services levy of up to $.29 per thousand dollars of assessed valuation for the period of 1998 through 2003; and WHEREAS, RCW 84.52.069 requires the County to seek authorization from cities with the population of 50,000 or more to place the measure on the ballot; and WHEREAS, the City of Federal Way has a population of over 75,000 people and cities in Kinq County of greater than 50,000 in population must approve the Emergency Medical Services ("EMS") levy being placed on a county-wide ballot; and WHEREAS, it has been to the benefit of the citizens of the City of Federal Way to support the Kinq County Fire Protection District ("KCFPD") #39's participation in the county-wide Res . # 97-259 , Paqe 1 o�� INA� � � cooperation of deliverinq Advanced Life Support ("ALS") and Basic Life Support Services; and WHEREAS, KCFPD #39 delivers Basic Life Support services, hosts South King County paramedics within a fire station and this relationship enhances EMS to our citizens and those of neiqhboring jurisdictions; and WHEREAS, the demands for EMS is increasinq and the EMS Strategic Plan has identified possible methods aimed at controlling the future demands for services and for controlling the proposed levy rate of twenty-nine cents (29C) per thousand dollars ($1,000) of assessed valuation; and WHEREAS, the City of Federal Way supports the delivery of ALS services in South King County, and supports the future administration of the medic proqram in Federal Way by KCFPD #39 if in the future King County elects to deliver such services partially or totally from an aqency other than the King County EMS division. NOW THEREFORE, THE CITY COUNCIL OF THE CITY OF FEDERAL WAY HEREBY RESOLVES AS FOLLOWS: Section 1. Ballot Measure. The Federal Way City Council authorizes King County to place the King County EMS levy renewal before the voters at the November 1997 general election with a countywide property tax levy rate of twenty-nine cents (29C) or less per thousand dollars ($1,000) of assessed valuatioa. If in the future King County elects to deliver such services partially or totally from an agency other than the King Coun�y EMS division, the Res . # 97-�9 . Paqe 2 � . • County agrees to negotiate with the City of Federal Way and KCFPD No. 39 the option to provide, manage, and/or administer ALS services in KCFPD No. 39. Section 2. Severabilitv. If any section, sentence, clause or phrase of this resolution should be held to be invalid or unconstitutional by a court of competent jurisdiction, such invalidity or unconstitutionality shall not affect the validity or constitutionality of any other section, sentence, clause or phrase of this resolution. Section 3. Ratification. Any act consistent with the authority and prior to the effective date of the resolution is hereby ratified and affirmed. Section 4. Effective Date. This resolution shall be effective immediately upon passage by the Federal Way City Council. RESOLVED BY THE CITY COUNCIL OF THE CITY OF FEDERAL WAY, WASHINGTON, this 2nd day of September , 1997. CITY OF FEDERAL WAY �_.�- �,. YOR, MAHLON S. PRIEST ATTEST: � � � �,�' � C �� CI Y CLERK, N. CHRISTIN GREE , Res . #� , Page 3 � APPROVED AS TO FORM: T Y, LONDI K. LINDELL FILED WITH THE CITY CLERK: 08-26-97 PASSED BY THE CITY COUNCIL: 09-02-97 RESOLUT I ON NO . 97-259 K:\RESO\EM3ELECT.97 PW 97-263 ❑ Res . #k�, Page 4 \_J • CITY OF �� _ � _ � 33530 1 ST WAY 50UTN S�ptember 3 1997 Mr. Jeremy Ward King County 999-3rd Ave. - Suite #700 Seattle, WA 98104 Re: Dear Mr. Ward: �2Q6) 507--10t)0 FEOERA! 4VAY. :'JA 9F3�03-6'210 King County Emergency Services Ballot Resolution Enclosed, please find a copy of the City of Federal Way's Resolution 97-259, authorizing King County to place, on the November 1997 General Election Ballot, a measure regarding a county- wide ballot proposition for funding emergency medical services ("EMS"), pursuant to RCW 84.52.069, as amended. This resolution was passed by the Federal Way City Council on Tuesday, September 2, 1997, at the Regular City Council Meeting. Please let me know if we can be of further assistance to you. Sincerely, �.'-�-F'.i �,�7�-'� �� Bob Baker Deputy City Clerk � cc: Jim Hamilton, FD #39 Law Department � From: Chris Green Toi BOBB Date: August 29, 1997 (Friday) 10:33 am Subjects NEEDS CERTIFIED COPY � of KC Emergency Services Ballot Resolution...please mail on Wednesday, the 3rd if at all possible, to: Jeremy Ward Ring County 999-3rd Ave, ,�700 Seattle, WA 98104 Thanks! cq �\� % / � �\� �� / � C2"1'Y Ol�' �'EDE.R.4L NrAY OFFICE Dl� TSE CIT �' CI.�ER�C . City Clerk Deputy City Clerk 33530 -1st Way South Federal'Way, WA 9$003 Ia�TE: '�Q: �Ax #: F1�OM: r ► � , • • ! . �tL J � � �.. � . � , �� v _� . .L�. . �.__jr'� . � *� . ! ► r �r , [] Chris Green, Cxty C�erk or [+�''� Baker, Deputy Clerk (206) 661-4070 (206) 661-407]� . __.. .....-.�.,rrr.,�Yn nrltmn C`T1L''TiT _ � fJ 09/08/97 MON 08:55 FAX 2066614075 City of Federal Way f�001 � • MEETING DATE: September 2, 1997 ITEM# ..-•• .............................................................................................................................................••-------................--------•••--...., CITY OF FEDERAL WAY City Council AGENDA ITEM ... SUBJECT: Kin� County Medical Services Levx ............................................ ...................................... ......----- .... .... .......................................... CATEGORY: X CONSENT _ORDINANCE _BUSINESS HEARING —� _RESOLUTION 5TAFF REPORT PROCLAMATION STUDY SESSION 01'HER BUDGET IlVIPACT: Amount Budgeted: $ Ezpenditure Amt: $ Contingency Reqd: $ .................................................•-•--.............................................................................................................................................................................................. ATTACHMENTS KC Fire District #39 memorandum to the August 7, 1997 meeting of the Public Safety & Human Services Committee 1998-2003 Emergency Medical Services Strategic Plan Dratt Resolution .......................................................................••--•-•--------•------••---..................................................................--••----........................................................................ SU1ViMARYBACKGROUND Emergency Medical Services (EMS) in King County are funded in part, through a special countywide property tax levy that is in effect for a duration of six (6) years. Fire District #39 Administrator Jim Hamilton presented the Public Safety and Human Services Committee a Draft Resolution authorizing King County to place the property tax levy measure on the November 1997 general election ballot. Approval of the ballot measure is contingeM upon the City of Federal Way, King County Fre P�otection District #39 (KCFPD►, and King County entering into a signed agreement, prior to placement on the ballot, which agreement shall grant KCFPD #39 the option to provide, manage, and/or administer Advance Life Support services. Mr. Hamilton also provided the Committee with copies of the 1998-2003 Emergency Medical Services Strategic Plan prepared by a committee formed in 1996. C`ITY COUNCIL C011/IlVIITTEE RECOIVIlVIENDATION At its August 7 , 1997 meeting, the Public Safety and Human Services Committee forwarded the draft Resolution to the September 3, 1997 meeting of the full City Council, with the recommendation to authorize King county's placement o�F}e�prqp�,�iti�n„on the November 1997 • CITY MANAGER RECOMMENDATION: .. . ............................................................................................................................................. �� '' . . ..... APPROVED FOR INCLUSION IN COUNCIL PACKET: � _ (BELOW TO BE COMPLETED BY CITY CLERK'S OFFICE) • � COUNCIL ACTION: ✓PPROVED DENIED TABLED/DEFERRED/NO ACTION �:��..� COUNCIL BILL # lst Reading Enactment Reading ORDINANCE # RESOLUTION # •� u i � • KING COUNTY FIRE PROTECTION DISTRICT NO. 39 FEDERAL WAY FIRE DEPARTMENT 31617 - 1STAVENUE SOUTH FEDERAL WAY, WASHINGTON 98003-5299 DATE: July 24, 1997 TO: Michael Park Public Safety Committee . �� FROM. Jun Hamilton, Fire District 39� SUBJECT: King County Emergency Medical Services Levy BACKGROUND: Emergency Medical Services in King Counry are funded, in part, through a special county-wide property tax levy that is in effect for a duration of six years. The EMS system in King County is a tiered response system that has local fire agencies providing the first response, with paramedic response following when necessary. The taxes from this levy are utilized to fund services in three areas: Basic Life Support (BLS) - These funds support local fire agencies with the provision of BLS services through firefighter/EMT's (Emergency Medical Technicians). BLS providers provide the first response to traumatic injuries and full response to non life-threatening injuries. The levy funds are utilized in a variety of ways to help cover the costs of training, supplies and, to a very limited degree, staffing. District 39 will receive approximately $581,000 in BLS funding in 1997. Advance Life Support - These funds support the paramedic units that are strategically located throughout the county. We have one King County Emergency Medical Services (KCEMS) paramedic unit located in our fire station at 3700 South 320�'. The paramedic units respond to serious life threatening injuries. Regional Services - These funds support county-wide training for EMT's, paramedics and dispatchers, prevention programs, medical control, administration and overhead expenses (rent, utilities, etc.). Business Phones: Seattle 206-839-6234 Tacoma 206-927-3118 FAX: 206-946-2086 King County Fire District # 39 is an equal opportunity employer. � • Early in 1996, KCEMS began a planning process to develop the accompanying strategic plan that would define the future roles and responsibilities of EMS providers in King County and esta.blish a framework for moving the EMS system into the 21S` century. I co-chaired this committee with Dr. Alonzo Plough, Director, Seattle/King County Department of Public Health. This plan represents a comprehensive evaluation of the demand, provision and funding for EMS services. Fundamental to the upcoming 1998 - 2003 levy period was the trend for increasing numbers of emergency responses. The plan addressed those trends through four major strategic initiatives that are designed to control demand for services to keep tax increases in line with inflation. The proposed levy for 1998 - 2003 reflects those strategies. As part of the county-wide levy process, all cities with populations in excess of 50,000 must authorize, through resolution, the placement of the levy on the ballot. The language of the proposed resolution has been modified from the one passed 6 years ago by the City Council. The changes reflect a requirement that KCEMS develop an agreement with Fire District 39 that provides our fire district the option of becoming an Advanced Life Support provider should the opportunity arise. Cunently, King County is the provider of ALS services in south King County. Bellevue Fire Department, Evergreen Hospital District, Shoreline Fire District and Seattle Fire Department are providers in the remaining areas of the county. Although we are currently pleased with the service that we receive, there are significant benefits to combining BLS and ALS into the fire service. This agreement would allow Fire District 39 the opporiunity to become the ALS provider should King County elect to discontinue the present anangement. RECOMMENDATION: The Committee to forward the EMS levy resolution to full Ciry Council with recommendation for approval. i 1998 — 2003 • Emer enc Medical g Y Services Strate ic Plan g June, 1997 � Seattle/King County Department of Public Health King County Emergency Medical Services Ilivision � 1998 - 2003 EMS STRATEGIC PLAN TABLE OF CONTENTS ' �) � ; l �, � �� EXECi.T'I'IVE SiJ1VIMARY ...................................................................... CHAPT'ER ONE: Introduction and Background ............................... 8 CHAPTER TWO: Strategic Plan ........................................................ 20 CHAPTER THREE: Financial Plan .................................................... 28 CHAP'TER FOUR: Implementation Plan & Schedule .................... 40 •: CHAPTER FIVE: Contingency Planning Process ........................... 48 APPENDIX A — Maps APPENDIX B — Seattle EMS , �� 1 �� f PREFACE T11e 1998-2003 EMS Strategic Plan builds upon the EMS Division's 1992 -1997 Master Plan and its subsequent updates. The original plan, developed in 1991, represents a milestone in the history of collaborative effort between the City of Seattle and the King County EMS systems. It provides the foundation for ongoing coordination, collaboration, and regionalization. This 1998-2003 EMS Sfirategic Plan is limited to the County portion of the EMS systnn. Linless otherurise indicated, �nancial and statistical data p�rsented in this plan exclude Seattle Fire Depa�tment EMS at their request. Appendix B pro- vides information, developed by the Seattle Fire Depart►nent and the Cifiy of Se- attle Of,�ice of Management and Planning regarding Sea#le's EMS funding plan. ' �I ,. .� I PREFACE The 1998-2003 EMS Strategic Planbuilds upon the EMSDivision's 1992-1997Master P1an and its subsequent updates. The original plan, developed in 1991, represe.nts a milestane in the history of collaborative effort between the City of Seattle and the King County EMS systems. It pmvides the foundation for ongoing coordination, collaboration, and regionalization. Thfs 1998-2003 EMS Strategic Plan is limited to the County portion of the EMS systenc. Linless otheriuise indicated, financial and statistical data pnesented ue this plan exclude Seattle Fire Department EMS at their request. Appendix B pro- v�des infor►nation, developed by the Seattle Fire Department and the City of Se- attle OfJR'ice of Management and Planning regarding Sea#le's EMS funding plcrn. • ACKNOWLEDGEMENTS , �I � � � The ENIS Division would like to thank members of the EMS Strategic Plan Steering Coaunittee who volunteered their time to assist in this planning effort. The assis- tance of the following people is greatly appreciated. Dr. Alonzo Plough, CaChair Director, Seattle/King County Deparhnent of Pubtic Health Jim Hamilton, CaChair Administrator, King County Fire District #39 Tom Fieldstead, Former CaChair Former Chief, Kirkland Fire De�rtment Norm Angelo Chief, Kent Fire Department jim Batdorf EMT/Fire Fighter, Shoreline Fire Department Bob Berschauer Directar of Operations, Shepard Ambulance Michael Brooks (former member) Battalion Chief, Seattle Fire Department Mark Bunji (former member) EMT/Fire Fighter, Shoreline Fire Department Michael Copass, MD Medical Directar of Seattle EMS, Harborview Medical Center Paul Goldberg Blue Cross of Washington and Ataska Paul Harvey Paramedic, Seattle Fire Department and Director of Seattle Fire Fighters LInion Local 27 Tom Heame Murutger, EMS Division • • Chris Heminger EMT, Auburn Fire Department and Sth District Representative of the WA. State Council of Fire Fighters jon Kennison Commissioner, Shoreliree Fire Department Marcus Kragness Chief, Bothell Fire Department Pete Lucarelli Chief, Bellevue Fire De�rtment john Murray MD M�iical Program Director, King Counfy EMS john Pritchard Battation Chief, Seattle Fire Department Ted Rail Spokane Paramedic and 1st Districf Representative of the WA. State Council of Fire Fighters Saza Shannon Paramedic, King County Medic One Dwight Van Zanen Chief, King County Fire District #43 TECHNICAL ADVISORS Peter Harris City of Seattle, Offece of Management and Budget The broad-based membership of the Steering Committee together with an open process that sought input from many interested canstituencies, assures that the 199� 2003 EMS Strategic Plan cleazly reflects the collective thoughts and perspectives of the communities served by the EMS system. The EMS Division would also like to thank those who attended the Steering Com- mittee meetings, participated in the subcommittee meetings, focus groups, and workgroups, and cantributed valuable insights to make this Strategic Plan pos- sible. Thank you. � EXECUTIVE SUMMARY 1998 -2003 EMERGENCY MEDICAL SERVICES STRA.TEGIC PLAN PURPOSE The purpose of the 1998 - 2003 Emer- gency Medical Services Strategic Plan is to define the future mles and responsi- bilities of EMS providers in King County and to establish a framework for mov- ing the County's EMS system into the 21st century. The Plan sets new EMS policies, identifies four new strategic di- rections for the County, and provides a financing plan to maintain existing out- of-hospital emergency services and to implem�t the strategic initiatives. The Plan aLso allows flexibility to address emerging health needs through coordi- nation with other public and private health care organizations. The financial plan focuses on the EMS levy. Seattle Medic One and King County EMS services are partially funded through a single, county-wide property tax levy that is voter approved every six years. In November,1997, vot- ers will be asked to approve the EMS property tax levy for the next six years. This 1998 - 2003 Emergency Medical Ser- vices Strategic Plan pmvides elected of- ficials, voters, and the EMS community a description of the EMS services to be supported through the levy. PLANNING PROCESS � Early in 19%, the EMS Division of the Seattle/King County Department of Public Health established the EMS Stra- tegic Plan Steering Committee to de- velop this Plan. Committee members represented the full range of EMS pro- viders, including: paraznedics, ENfT's, physicians, urban and rural fire depart- ments, labor, health plans, the health department, private ambulance compa- nies, and fire commissioners. Numerous focus groups, subcoaunittees, and tech- nical workgroups have been convened throughout the planning process to gather additional perspectives. All meet- ings were open to the public and publi- cized through newsletters with a mail- ing list exceeding 200 interested parties. The newsletter summarized the Steering Committee's progress and provided a forum for public input and information dissemination. The results of the Steering Committee's efforts are detailed in this 1998 - 2003 EMS Strategic Plan. The Executive Sum- mary highlights major new strategic di- rections to be explored and implemented throughout the next six years and sum- marizes the proposed financing plan to achieve future goals and objectives. �� , � � � BACKGROUND: SEATTLE MEDIC ONE AND KING COUNTY EMS SYSTEMS Seattle Medic One and King County's EMS system aze structured as "tiered response systea�s." The purpose of tiered response is to assure that callers to 9-1-1 for medical emergencies receive efficient and effective care by the most appropri- ately trained level of provider. This in- cludes basic life support (BLS) services pmvided by Emergency Medical Tech- nician (BMT�/fire fighters and advanced life support (ALS) services provided by paramedics. As an incremental cost to the fire service, EM'T/fire fighters have 120 hours of EMS training, allowing them to respond rap- idly to all EMS calls and deliver imme- diate basic life support services. For more serious emergencies, pazamedics with 3,000 hours of specialized univer- sity training, are also dispatched to the scene to pmvide extensive out-of-hospi- tal emergency medical care for serious injuries and illnesses. The tiered re- sponse system involves a continuum of care with the following components: • Citizen CPR • Universal access through 9-1-1 • Criteria based dispatch triage guide- lines • Rapid response to all EMS calls by Emergency Medical Technician/Fire Fighters who deliver basic life sup- port (BLS) services • Rapid response to about 33% of all EMS calls by Harborview trained pazaznedics who deliver advanced life support services • Integral participation of emergency medical technicians employed by private ambulance companies in continuing patient care and trans- port • Emergency room physicians in des- ignated hospitals who legally pro- vide uniform medical direction and oversight to EMS providers and serve as medical control points for paramedic units � • A regional system that emphasizes uniformity across jurisdictions, ex- cellent training, effective research, and quality assurance. CITRENS SERVED BY KING COUNTY'S EMS SYSTEM: 1992 TO 1896 The number of calls to 9-1-1 for emer- gency medical services thmughout King County increased from 62,300 responses in 1992 to an estimated 81,100 responses in 1996 (excluding Seattle). This is a 30% increase in total services delivered by EMT/fire fighters, averaging 6% per yeaz growth in call volume. The number of EMS calls that received a paramedic response increased from 21,950 to 27,000 over the same time frame (excluding Seattle). This is a 23% in- crease in services delivered by paramed- ics, averaging 4.6% increase in call vol- ume annually. This rate of growth exceeds population growth or other demographic changes that may affect the demand for EMS ser- vices. Variables that may explain excess demand for services reflect overall changes within the broader health care system, such as eazly hospital discharges, increased use of outpatient procedures, and increased use of home health ser- vices. Additionally, there has been an increase in social pmblems leading to medical emergencies involving domes- tic violence and substance abuse. In- creasingly, the EMS system is becoming the social and health services safety net. As planned in 1991, the EMS Division increased King County's ALS service capacity from seven to fourteen ALS units to serve growth in service volumes that occurred during the 1992 -1997 1evy period. This expansion has associated costs to be sustained through the next levy period. . C' � � 2 BACKGROUND: SEATTLE MEDIC ONE AND KING COUNTY EMS SYSTEMS Seattle Medic One and ICing County's EMS system are structured as "tiered response systems." The purpose of tiered response is to assure that callers to 9-1-1 for medical emergencies receive efficient and effective care by the most appropri- ately trained level of provider. This in- cludes basic life support (BLS) services provided by Emergency Medical Tech- nician (EM'1�/fire fighters and advanced life support (AIS) services provided by paramedics. As an incremental cost to the fire service, EMT/fire fighters have 120 houts of EMS training, allowing them to respond rap- idly to all EMS calls and deliver imme- diate basic life support services. For more serious emergencies, pazamedics with 3,000 hours of specialized univer- sity training, are aLso dispatched to the scene to provide extensive out-of-hospi- tal emergency medical care for serious injuries anc� illnesses. The tiered re- sponse system involves a continuum of care with the following components: • Citizen CPR • Universal access through 9-1-1 + Criteria based dispatch triage guide- lines • Rapid response to all EMS calls by Emergency Medical Technician/Fire Fighters who deliver basic life sup- port (BLS) services • Rapid response to about 33% of all EMS calls by Harborview trained paramedics who deliver advanced life support services • Integral participation of emergency medical technicians employed by private ambulance companies in continuing patient care and trans- P�rt • Emergency room physicians in des- ignated hospitaLs who legally pro- vide uniform medical direction and oversight to EMS providers and serve as medical control points for paramedic units A regional system that emphasizes uniformity across jurisdictions, ex- cellent training, effeckive reseazch, and quality assurance. CITIZENS SERVED BY KING COUNTY'S EMS SYSTEM: 1992 TO 1996 The number of calls to 9-1-1 for emer- S��Y medical services thmughout King County increased from 62,300 respunses in 1992 to an estimated 81,100 responses in 19% (excluding Seattle). This is a 30% increase in total services delivered by EMT/fire fighCers, averaging 6% per yeaz growth in call volume. The number of EMS calls that received a paramedic response increased from 21,950 to 27,000 over the same time frame (excluding Seattle). This is a 23% in- crease in services delivered by pazamed- ics, averaging 4.6% increase in call vol- uate annually. This rate of growth exceeds population growth or other demographic changes that may affect the demand for EMS ser- vices. Variables that may explain excess demand for services reflect overall changes within the broader health care systein, such as early hospital discharges, increased use of outpatient procedures, and increased use of home health ser- vices. Additionally, there has been an increase in social pmblems leading to medical emergencies involving domes- tic violence and substance abuse. In- creasingly, the EMS system is becoaung the social and health services safety net. As planned in 1991, the IIvIS Division ,+ increased King County's ALS service � capacity from seven to fourteen AIS units to serve growth in service volumes that occurred during the 1992-19971evy period. This expansion has associated costs to be sustained through the next levy period. �� ---- ...-.- 2 � Future population growth trends and ongoing aging of the population will in- crease the need for EMS services in the future. The 1998 - 2003 EMS Strategic Plan provides a mechanism to assure continued capacity expansion to meet natural growth. The Plan also provides new strategies for addressing increased EMS call volume resulting from other factors. FUTURE CHALLENGES Assessment of the current EMS system 4. in King County identified four issues and concerns to be addressed during the next six years. 1. Is current EMS ler�y funding sujj``icient to sustain ongoing expansion of ALS service capacity to meet continued growth in EMS services through 2003? As with most other public services, it is likely that EMS funding will be limited in the future. To manage fu- ture costs, this Plan focuses on ser- vice delivery methods that reduce the need for ongoing expansion of ALS services throughout King County. 2. What is the most effective and effxcient role for EMS providers? As a key access point to needed so- cial and health services, EMS provid- ers will continue to serve a small but critical role as part of the larger "so- cial and health care safety net." EMS's prunary role is to provide emergency medical services in out- of-hospital settings and to refer non- emergent and primary care patients to more appropriate providers. 3. Can existing EMS services be uHlized more effectively to manage the n�d for futur¢ cupacity expansion? The 1992 —1997 1evy cycle focused on internal prograzn improvements � and capacity expansion to meet pro- jected growth in demand for ser- vices. With eminent lunitations on public funding, a major 1998 - 2003 goal is to manage future AIS expan- sion through two methods: Increase utilization of euisting ALS capacity; and Work with other public and private health care providers to reduce the rate of growth in the demand for EMS services. In vietv of potential funding limitations, how should ALS, BLS, and Regional Services funding decisions be made in the future? The County's 35 BLS agencies and four AIS pmviders recognize that the benefits of regionalization, col- laboration, and cross-jurisdictional coordination faz exceed the indi- vidual benefits associated with other EMS service delivery and funding mechanisms. With multiple and sometimes com- peting funding and program priori- ties facing the County's EMS provid- ers, this strategic and financial plaz► emphasizes cooperative efforts to meet emerging challenges to the sys- tem. Regional service �elivery and funding decisions will be made co- operatively and will balance the needs of ALS, BLS, and regional ser- vices from a system-wide perspec- tive. 1998 - 2003 EMS STRATEGIC INITIATIVES The 1998 - 2003 Strategic Plan identifies four major strategic initiatives for the next six years: 1, Diminish the rate of growth in de- mand for EMS services to 3% growth per yeaz through: ' �� l ,` �; 3 � Public education Injury and illness prevention and intervention Refesal to other types of assis- tance when medically appropri- ate 2. Use existing resources more effi- ciendy by: • Revising and refiniilg ALS dis- pa�h triage criteria • Establishing a broader azray of transport destinations • Coordinating with private am- bulance companies • RevisingALS perfornnance stan- dards • Explore varyin8 response time standards for medically appro- priate calls • Exploring alternative ALS unit scheduling options. 3. Enhance existing pmgrains and add new programs to meet emerging community needs. • Enhance dispatcher training • Enhance public education on the appropriate use of EMS services • Enhance responsiveness to the needs of special populations • Develop, unplement and/or en- hance a regional continuous quality ianprovement pmgram. � Establish an EMSAdvisory Commit- tee to assist the EMS Division with unplementation of the 1998 — 2003 EMS Strategic Plan. � Refinements to the ALS dispatch triage criteria are expected to reduce the per- centage of EMS calls receiving an ALS response from 33% to 30%, thereby re- ducing the growth in AIS call volume by 5,000 calls in 2003. Cost savings for ALS services alone are projected to be $3.0 million over the six years through even better utilization and management of existing resources. Collaboration and coordination with other public and private health care or- ganizations will strengthen the ability of EMS providers to develop and 'unple- ment the new strategies. The 1998-2003 Strategic Plan pmvides a structure for working with other health care er�tities to promote more cost-effective and effi- cient use of public as well as private health care resources. 1 gg8 — 2003 FlNANCIAL PLAN The six-year financial plan for King County's EMS System is preaiised upon a rnmbination of program and service initiatives to control costs, increase op- erating efficiencies and manage contin- ued growth in demand for service. To accomplish this, the financial Plan incor- porates the following principles• 1. 2. Successfui implementation of the strate- gi� initiatives is projected to reduce the potential growth in EMS call volume by 10%. All calls to 9-1-1 will receive assis- tance, but in the future this may include referral by dispatch to other social and health services when appmpriate. 3. 4. The EMS levy needs to support con- tinuation of quality services and pro- vide adequate funding to develop the 1998 — 2003 strategic initiatives. Funding decisions will be ap- proached from a system-wide per- spective. The financing plan recognizes indi- vidual jurisdictions' need for local autonomy to meet their communi- ties' expectations for EMS services. The plan depends upon coordina- tion and rnllaboration between EMS providers and other health care en- tities. ,�' �� 4 • Public education • Injury and illness prevention and intervention • Refenal to other types of assis- tance when medically appropri- ate 2. Use existing resources more effi- ciendy by: • Revising and refining AIS dis- patch triage criteria • Establishing a broader array of transport destinations • Coordinating with private am- bulance companies • RevisingALS performance stan dards • Explore varyin8 response time standards for medically appro- _ priate calls • Exploring alternative ALS unit scheduling options. 3. Enhance existing programs and add new programs to meet emerging community needs. Refinements to the ALS dispatch triage criteria are expected to reduce the per- centage of EMS calls receiving an AIS response from 33% to 30%, thereby re- ducing the growth in AIS call volume by 5,000 calls in 2003. Cost savings for ALS services alone are projected to be $3.0 million over the six years through even better utilization and ma:►agement of existing resources• Collaboration and coordination with other public and private health care or- ganizations will strengthen the ability of EMS pmviders to develop and imple- ment �enew strategies. The 1998-2003 Strategic Plan pmvides a structure for working with other health care entities to promote more cost�ffective and effi- cient use of public as well as private health care resources• 1998 — 2003 FlNANCIAL PLAN The six-year financial plan for King County's EMS System is premised uPon a rnmbination of program and sen'ice irutiatives to control costs, increase op- erating efficiencies and manage contin- ued growth in demand for service. To accomplish this, the financial Plan incor- porates the following principles. , • Bnhance dispatcher training • Enhance publiceducation on the appropriate use of EMS services • Enhance responsiveness to the needs of special populations • Develop, unplement and/or �- hance a regional continuous quality improvement program. 4. 1. The EMS levy needs to support con- tinuation of quality services and pro- vide adequate funding to develop the 1998 — 2003 strategic initiatives• Establish an EMSAdvisory Commit- tee to assist the EMS Division with implernentation of the 1998 — 2003 EMS Strategic Plan. Successful implementation of the strate- �i� initiatives is projected to reduce the potential growth in EMS call volume by 10%. All calls to 9-1-1 will receive assis- tance, but in the future this may include referral by dispatch to other social and health services wh� appropriate. 2. Funding decisions will be ap- proached from a system-wide per- speekive. 3. The financing plan recognizes indi= .- -_ vidual jurisdictions� need for local autonomy to meet their communi- ties' expectadons for EMS services. 4. The plan depends upon coordina- tion and collaboration between EMS providers and other health care en- tities. , �� , ��f 4 • 5. 6. 7. 8. The EMS Division is responsible for coordination and facilitation of col- laborative activities necessary to as- sure the success of this regional stra- tegic and financial plan. As an essential public service, Ad- vanced Life Support services will continue to be supported primarily by the EMS levy. As an essential public service, Basic Life Support services will be funded through a combination of local taxes that support fire service functions together with EMS levy funds to support the incremental cost of BLS. New sources of revenue may be needed to fund enhancements to the EMS system which may include grants and other non-levy funds. The EMS levy is a significant source of revenue for the EMS system, particularly for AIS services and negional programs. For the last 12 years, the authorized levy rate in Seattle and King County has been $0.25 per $1,000 of assessed property value. State law allows jurisdictions to levy as much as $0.50 per $1,000. Throughout the current levy period, in- creases in property valuations have not maintained pace with the growth in de- mand for EMS services and the added expense needed to serve this demand. Additional sources of revenue, such as county CX funds, grants, in-kind contri- butians iromALS providers, and cash ac- cumulations of levy funds eazly in the levy period have allowed the EMS sys- tem to grow in response to increased demand. The vaziance between EMS costs and EMS levy revenues is widening. Finan- cial analysis indicates that the EMS sys- tem will incur operating deficits during the ensuing levy period if the levy is maintained at $0.250. Other sources of • revenues will be insufficient to cover the expected deficits. A combination of cost-saving programs together with an increase in the EMS levy rate is needed to provide EMS services through the next levy cycle. Projected cost savings will result from: • strategic initiatives to manage growth in demand and improve uti- lization of existing resources; � focus of EMS levy funds on core re- gional functions that support the EMS system; • continuation of County CX support at current funding levels; � development of a joint purchasing program for ALS and BLS provid- ers; � implementation of a more cost-effec- tive vehicle replacement, salvage, and retrofit pmgrazn; • indexing future cost increases to re- flect CPI; and • an expectation that ALS providers will continue to provide in-kind fi- nancial contributions to cover indi- rect program costs. Without these changes, the EMS system would need to increase its levy rate fmm $0.250 per $1,000 of assessed value to $0.340. With the cost-reducing strategies, the levy rate can be lunited to $0.295 per $1,000. This will assure continuation of current services and it will provide suf- ficient resources to implement the 1998 — 2003 strategic initiatives. It is anticipated that the strategic initia- tives will be successful and will allow the oPPoltluiit}� to IILnimi�p �pWth iti EM$ levy funding in the later years of the levy period. As a matter of public policy, the EMS Division will monitor levy funds and expenditures to assure the ending fund balance in 2003 meets the County's 5% reserve requirement. This may result in an EMS property tax rate, in the later years of the levy cycle, that is less than the a►aximum allowable of $0.295 as rec- ommended in this plan. �, 1 �� 5 � U The following table summarizes the his- torical and projected revenues and ex- penses for the County's EMS system and reIIects the strategic initiatives, financial assumptions and policies in this plan. The EMS Strategic Plan Steering Com- mittee thoroughly examined program and funding altematives and identified efficiencies that are practical and support the quality of care and level of EMS ser- vices expected by the public. The as- sumptions inrnrporated into this financ- ing plan are aggressive, but they reflect cun+ent perspectives on future EMS pro- gram requirements and respond to pub- liC SQTitlII1e11t to minimi�.P {�(es. It iS � ficult to project future funding require- ments over a six yeaz period and it is al- ways possible that the assumptions in this Plan may be different from actual events. In anticipation of this, the 1998 — 2003 Strategic Plan includes a contin- B��Y P P�� t will allow EMS providers to proactively respond to changing external events. � C � � ` � 6 .� � The following table s»mmari��s th� his- torical and projected revenues and ex- .. penses for the County's EMS system and reflQCts the strategic initiatives, financial assumptions and policies in this plan. The EMS Strategic Plan Steering Com- mittee thoroughly examined program and funding altematives and identif'ied efficie�uies that are practical and support the quality of care and level of EMS ser- vices expected by the public. The as- sumptions i�orporated into this finanr ing plan are aggressive, but they reflect current perspectives on future EMS pro- gram requirements and respond to pub- liC 8@IitlmelLt t0 IIL nim;�o tBXES. It is dif ficult to project future fundin8 �lti"re' ments over a six yeaz period and it is al- ways possible that the assumptions in this Plan may be different from actual ev�ts. In anticipation of this, the 1998 — 2003 Sirategic Plan includes a contin- S��Y P��S P� that will allow EMS providers to proactively respond to changing extemal events. . 6 �i KING COUNTY EMERGENCY MEDICAL SERVICES HISTORICAL AND PROJECTED REVENUES AND EXPENSES Excludes Seattle EMS Levy FunAs (1) (a in thousandsl BEGINNING FUND BALANCE REVENUES EMS Levy - County Share Other Revenues(2) County CX Total County EMS Funds Total Available Funds (3) EXPENDITURES County ALS Services (4) County BLS Services Regional Services Strategic Initiatives (5) Total County Expenditures REVENUES LESS EXPENDITURES Adjustmenb (6) Ending Fund Balance Target Fund Balance l7) Historical Revenues and Facpenses Levv Rate: $0.25 1992 1993 1994 1995 1996 1997 Budgeted $2,850 $4,471 $5,716 $6,433 $5,907 $3,977 $16,484 $17,886 $19,070 $19,609 $19,784 $20,397 $274 $315 $587 $397 $297 $255 a375 $375 $375 $375 �375 $375 $17,133 $18,576 $20,032 $20,381 $20,456 $21,027 $19,983 323,047 $25,748 $26,814 $26,363 $25,004 $5,884 $10,878 $9,337 �6,522 $7,368 $7,707 $1,279 $1,536 �2.163 0 0 0 $13,685 $19,782 $19,207 $6,298 $3,265 $6,541 ($1,827) $2,451 ($108) $4,471 $5,716 $6,433 $10,767 $11,798 $12,735 $7,938 $8,017 $8.278 $2,286 $2,610 $2,68] 0 0 �60 $20,991 $22,425 $23,759 $5,823 $3,938 $1,25(1 $84 $39 � $5.907 $3,977 $1,29a $1,05] Projected Revenues and Expenses Levv Rate: $0.295 1999 2000 2001 : $1,290 �1,383 $1,397 $1,758 $1,409 $1,493 $24,600 $25.600 $26,500 $26.100 $28.600 $29,800 $103 $110 $112 $143 $112 $119 $375 $375 $375 $375 $375 $375 $25,040 $26,044 $26,945 $26,618 $29,087 $30,294 $26,330 $27,427 $28,341 $28,376 $30,496 $31,787 $13,452 �14,310 $14,543 $14,577 $16,313 $17,149 38.500 $8.700 $9,000 $9.200 $9,500 $9,800 $2,500 $2,600 $2,700 $2,800 $2,800 $2,900 $495 $420 $340 $390 $390 $390 $24,947 $26,030 $26,583 $26,967 $29,003 $30,239 $1,383 $1,397 $1,758 $1,409 $1,493 $1,548 $1,383 $1,397 $1,758 $1,409 $1,493 $1,548 $1,522 1 Seattle ler�y rer�rnues and expenses are excluded/rom this table due to d�rent 6udget methods 2 Includes interest income on accumulated reserves � 5% plus very limited amounts from designated timber taxes and puWic donations 3 lncludes Revenues plus Beginning Fund Balance 4 IncluAes AIS contmcts, vrhicle replaaement, ruml ALS services, rcew AIS unit start-up funds 5 See Table 3.5 for dctailed 6udget 6.9djustments re/lect County Council designated reappropriations, encermbrances, and misc. budget adjustments 7 The King County Executive requires a 596 reserae at the dose of each levy cycle � . i � �_ � � CHAPTER 1 INTRODUCTION AND BACKGROUND PURPOSE OF THE EMS STRATEGIC PLAN The EMS Strategic Plan provides a roadmap to guide the County's EMS sys- tem through the 1998 - 2003 1evy period. The plan builds upon the 1990 Master Plan and establishes new policy direc- tions, describes a new strategic plan for the County's EMS system, and provides a fu►ancing plan and implementation schedule. 'This Plan is preceded by the 1995 EMS Master Plan Update which focuses on operational issues including: response time standards, numbers of ALS units needed, the location of ALS units throughout the county, 12-hour units, alternative staffing models, and other operational enhancements. The 1995 Master Plan Update provides a"nuts and bolts" approach for providing EMS services, and this Strategic Plan estab- lishes policy directions for moving the County's EMS system into the 21st cen- �'�• EMS SYSTEM ORGANIZATIONAL DESIGN 'The past twenty-five years has seen the development of a regional EMS system in the greater King County area. This system is based on the delivery model developed in the City of Seattle in the • late 1960's. Pioneered by Leonard A. Cobb, M.D and Gordon vckery, Former Chief of the Seattle Fire Department, the EMS program now incorporates a medi- cally-oriented, tiered response system. Major components of the system func- tionally embrace the full continuum of care for out-of-hospital emergency ser- vices and include: � Extensive training of citizens in car- diopulmonary resuscitation. � Universal access to the system to all who call the countywide 911 emer- gency telephone number. � Call receipt and triage by dispatch- ers to ensure that (1) the most appropriate levels of emergency medical providers are sent to the scene, and (2) assistance to callers by dispatchers is provided until the response team arrives (including delivering phone instructions in CPR). • Rapid response and treatment at the scene by Emergency Medical Tech- nician (FM'I')/firefighters. • Provision of advanced emergency medical care to patients with serious injuries or illnesses by Harborview- trained paramedics. • Integral participation of EMT's em- ployed by private ambulance com- panies in continuing patient care and transport. • Physicians who provide legal medi- cal authority, uniform medical over- sight and medical direction to the EMS system. . �� 1 �� ' See also Emergency Medical Services Master Plan Reports. Seattle-King County Depm'hnt►�t of PuWic Health, EMS Division, Apri11990-1995. 8 `J Strong ties with local hospitals, especially those with emergency de- partment physicians and staff who serve as medical control points for pazamedic units. A systems approach which empha- sizes excellent training, effective re- search, and quality assurance as the key to successful prehospital patient care. The County's EMS system has adapted the Seattle Fire DepartmenYs Medic One Prograzn model to accommodate the de- mographic, geographic and jurisdic- tional uniqueness of King County. ALS in both Seattle and King County have been primarily supported by an EMS levy since 1979. Seattle utilizes EMS levy funds to support the spectrum of EMS services within the city. The County por- tion of the regional system uses the EMS levy funds to support pazamedic, fire department BIS and regional EMS pro- grams. The City of Seattle and the County's EMS system function collaboratively and coordinate services across jurisdictional boundaries. The two prograzns operate under sepazate administrative structures and the re- mainder of this report addresses the County's regional system. (See Appen- dix B for more information on Seattle's � p�SI'�-) Legal Authority The King County EMS program serves as a constituent of the statewide Emer- gency and Trauma Care System de- scribed in RCW 18.71.200 - 18.71.215, Chapters 18.73 Sections 70.68 and 70.24. This legislation is administered through WAC 246-976: Emergency Medical Ser- vices and Trauma Care System. AllALS and BLS personnel in Seattle and King County meet or exceed state EMS certi- fication standards defined in RCW and WAC. Wfthin the state system, King County is designated as the "Central Region." The � EMS Division is an active participant in the Central Region EMS and Trauma Council and supports the county's trauma registry and other council activi- ties. The County's EMS System The County's EMS program serves over one million residents and 60,000 busi- nesses located in 19 cities and 16 fire dis- tricts throughout King County. This azea covers approximately 1,000 square miles of urban, rural, and wilderness areas. EMS response times, transport times and proximity to hospital services are chal- lenged by geographic barriers, distance, time and traffic. Currendy, the King County EMS Divi- sion provides medical oversight to the system, helps coordinate regional ser- vices, and administers EMS levy funds under contract with 35 fire-based basic life support (BLS) providers and four agencies who provide pazamedic or ad- vanced life support (ALS) services. The four County ALS agencies include: • Bellevue Medic One operated by Bellewe Fire Department (4 units) • Evergreen Medic One operated by Evergreen Hospital Medical Center (4 units) • King County Medic One operated by King County EMS Division (6 units) � Shoreline Fire Departa►ent (1 ALS unit) Tfered Response System The regional tiered response system of 9-1-1, dispatch, BLS, and ALS enjoys an international reputation for innovation and excellence in out-of-hospital urgent and emergent caze. For over twenty years, the system has maintained the highest reported survival rates in the treatment of out-of-hospital cardiac az- rest patients across the nation. Resusci- tation rates averaging 17% for sudden cardiac arrest patients and 29% for those C � . ,� { 9 ,� � , � `; Strong ties with local hospitals, especially those with emergency de- partment physicians and staff who serve as medical control points for pazaznedic units. A systems approach which empha- CI7p excellent training, effective re- search, and quality assurance as the key to successful prehospital patient care. The County's EMS system has adapted the Seattle Fire Department's Medic One Prograpn model to accommodate the de- mographic, geographic and jurisdic- tional uniqueness of King County. ALS in both Seattle and King County have been primarily supported by an EMS levy since 19T9. Seattle utilizes EMS levy funds to support the spectrum of EMS services within the city. The County por- tion of the regional system uses the EMS levy funds to support paramedic, fire department BLS and regional EMS pro- grams. The City of Seattle and the County's EMS system function collaboratively and coordinate services across jurisdictional boundaries. The two programs operate under separate administrative structures and the re- mainder of this report addresses the County's regional system. (See Appen- dix B for more information on Seattle's EMS program.) Legal AuthoNty The King County ENiS program serves as a constituent of the statewide Emer- gency and Trauma Care System de- scribed in RCW 18.71.200 — 18.71.215, Chapters 18.73 Sections 70.68 and 70.24. This legislation is administere�l through WAC 246-976: Emergency Medical Ser- vices and Trauma Care System. Al1AIS and BLS personnel in Seattle and King County meet or exceed state EMS certi- fication standards defined in RCW and WAC. Within the state system, King County is designated as the "Central Region." The EMS Division is an active participant in the Central Region EMS and Trauma Council and supports the county's trauma registry and other council activi- ties. The County's EMS System The County's EMS program serves over one million residents and 60,000 busi- nesses located in 19 cities and 16 fire dis- tricts throughout King County. This area covers approximately 1,000 square miles of urban, rural, and wilderness areas. F1vIS response times, transport times and proximity to hospital services are chal- lenged by geographic barriers, distance, time and traffic. ' Currently, the King County EMS Divi- sion provides medical oversight to the system, helps coordinate regional ser- vices, and administers EMS levy funds under contract with 35 fire-based basic life support (BLS) providers and four agencies who provide pazamedic or ad- vanced life support (ALS) services. The four County ALS agencies include: • Bellevue Medic One operated by Bellevue Fire Department (4 units) • Evergreen Medic One operated by Evergreen Hospital Medical Center (4 units) • King County Medic One operated by King County EMS Division (6 units) � Shoreline Fire Department (1 AIS unit) Tiered Response System The regional tiered response system of 9-1-1, dispatch, BIS, and ALS enjoys an .. ••- intemational reputation for innovation and excellence in out-of-hospital urgent and emergent care. For over twenty years, the system has maintained the highest reported survival rates in the treatment of out-of-hospital cardiac az- rest patients across the nation. Resusci- tation rates averaging 17°/a for sudden cardiac arrest patients and 29% for those 9 � patients in ventricular fibrillation are typical in this region. By comparison, reported resuscitation rates as low as 1%- 2% are typical in other areas of the United States. Key to this success is integration of ser- vices into what the American Heart As- sociation recognized in 1991 as the "Chain of Survival." This concept stresses a systems approach to success- ful treatrnent of cazdiac arrest by identi- fying the interdependence of four essen- tial links that are directly tied to cardiac patient survival and health status. These links include: • early access to the EMS system through the 9-1-1 emergency tele- phone number; � early CPR (with instructions pro- vided by dispatchers, or provided by a trained citizen); � early defibrillation by EMT/ firefighters (electric shocks given to restore a heart rhythm); and • eazly pazamedic care. The success of the system is testimony to the coaunitment of all participants to providing high quality services to the residents of Seattle and ICing County. The County's Criteria Based Dispatch Guidelines are another key component of the tiered response system. 1Nhen a 9-1-1 medical emergency call is received by a dispatch center (see Appendix A, Map 1), the nearest fire department BLS unit is immediately called to the scene. Trained dispatchers use a series of pre- defined medical criteria for various types of inedical problems. If the patient's signs and symptoms meet specific crite- ria, then a pazamedic unit is aLso dis- patched to the scene to provide ad- vanced medical treatrnent for serious injuries and illnesses. Typically, both BLS and ALS units are simultaneously dis- patched when needed. � \J Bystander CPR—whether performed with the assistance of a dispatcher or done on the basis of previous training— is a critical component of the tiered re- sponse system. While most BIS provid- ers in the County are able to reach the scene within an average of four to six minutes, bystanders can improve patient outcomes by initiating CPR as soon as possible. The regional EMS system has been very successful in training citizens of all ages in CPR and has successfully incorporated "dispatcher assisted CPR" into dispatcher training. All medical emergency calls to the EMS system receive a BIS response by one of the 35 fire service agencies serving the cities and unincorporated areas of King County. This response may involve a fire engine, a BLS aid unit, and occasionally in Seattle, a first response may be handled by a private ambulance com- pany for medically appropriate calls. If dispatchers determine that the medi- cal emergency is potentially life ttu+eat- ening, then an advanced life support team of pazamedics is alsu dispatched to the scene. Curres►tly, about one-third of all EMS responses in the County receive both a BLS and an ALS response. The regional structure of the County's program and the tiered response system of resource deployment have made it possible to respond to growing demands for EMS services. This is also made pos- sible by uniform training and continu- ing education pmgrams, uniform dis- patch guidelines, and a strong commit- ment among the 35 BLS providers serv- ing the county to cooperate and coordi- nate their service delivery methods. Medical Control The County's tiered response system is based on a medical model that operates under the legal authority of the Medical Program Director (MPD). The MPD is responsible for training, medical control C� � 1 -, f 10 • supervision, and quality review of the County's Emergency Medical Techni- cians (EMT's) and pazamedic providers. The MPD delegates medical authority to other physicians who provide medical control to specific Medic One programs. Pazamedics and EMTs trained in defibril- lation operate as extensions of the phy- sician and are legally authorized to pro- vide care on a medical director's license. Other major functions performed by the Medical Program Director include estab- lishing patient care guidelines for treat- ment, triage, and transport; establishing and supervising training and continuing educatian programs; and recommending certification, recertification, and decerti- fication of EMS personnel. 8asic Life Suppo�t Servic� (BLS) Basic Life Support Services are pmvided by 1,800 EMT/firefighters employed by 35 different agencies throughout the County (see Map 2). EMT/firefighters receive 120 hours of initial training and hospital experience, and most have aLso received additional training in cardiac defibrillation. EMT/fire-fighters are cer- tified by the state of Washington which also requires ongoing continuing educa- tion to maintain certification. BLS beams are dispatched to all medically related calls to the EMS system. These fire de- partment based units typically arrive on the scene within four to six minutes af- ter dispatch. In 1996, EMT's responded to more than 133,800 calls countywide, of which 52,700 occurred in Seattle and 81,100 in the County. Advanced Life Suppo�t Services (ALS) King County paramedics are trained thmugh the Pazamedic Training Program at the University of Washington/ Harborview Medical Center (HMC) , and with the Seattle Fire Department's Medic One program. Pazamedics are trained to provide advanced emergency medical care to patients with serious or life threatening illne.ss or injury. This pro- � gram is one of the most advanced para- medic trairung prograzns in the world. All paramedics in Seattle and King County receive nearly 3,000 hours of training provided by leading physicians in emergency medicine, anatomy and physiology, pharmacology, and other subjects. There are currently 20 paramedic units in the greater Seattle-King County re- gion, with six pazamedic units in Seattle and 14 units in the County (see Map 3). A pazaznedic unit is typically staffed by two pazamedics and requires approxi- mately nine pazamedic FTE's (full time equivalent staff) to pmvide service 24 hours per day, 365 days per year. All six paraznedic units in Seattle are staffed by two paramedics at a time. However, the pazamedic prograzn in the County in- cludes a wider variety of stafEing con- figurations in keeping with different geo- graphic and demographic patterns. Eleven paramedic units in the County are staffed by two-pazamedics at a time and operate 24 hours per day. In addi- tion, there are two EMT/paramedic (EMT/P) units staffed by an EMT/ firefighter and one paramedic. EMT/P units are deployed in the more outlying areas of King County where response times for suburban-based units are typi- cally long. When necessary, these units are backed up by two-pazamedic units, and specific dispatch criteria exist to help send the additional paramedic unit whenever needed. These units currenfly respond to both BIS andALS responses. The County aLso operates two half-time ALS units, with an additional 12-hour unit planned for Southeast King County. These units are staffed with two para- medics at a time, operating 12-hours per day during peak workload periods. These units are effective in suburban az- eas which have rapidly growing workloads and long response times, but which have not yet grown busy enough to warrant a 24 hour unit. Over 60% of the workload occurring in a 24 hour C� ,� ,� , 11 supervision, and quality review of the County's Emergency Medical Techni- cians (EMT's) and paramedic providers. The NII'D delegates medical authority to other physicians who pmvide medical control to specific Medic One programs. Pazamedics and EMTs trained in defibril- lation operate as extensions of the phy- sician and are legally authorized to pro- vide care on a medical dirnctor's license. Other major functions performed by the Meclical Program Director include estab- lishing paiient care guidelines for treat- ment, triage, and transport; establishing and supervising training and continuing educati� progrants; and recommending certification, recertification, and decerti- fication of EMS personnel. Basic Life Support Services (BLS) Basic Life Support Services are provided by 1,800 EMT/firefighters employed by 35 different ageneies throughout the County (see Map 2). EMT/firefighters receive 120 hours of initial training and hospital experience, and most have also received additional trauung in cazdiac defibrillation. EMT/fire-fighters are cer- tified by the state of Washington which aLso requires ongoing continuing educa- tion to maintain certification. BLS teams are dispatched to all medically related calls to the EMS system. These fire de- partment based units typically arrive on the scene within four to six minutes af- ter dispatch. In 1996, EMT's responded to more than 133,800 calls countywide, of which 52,700 occurred in Seattle and 81,100 in the County. Advanced Lffe Support Services (ALS) King County paramedics are trained through the Pazaznedic Trauung Prograzn at the University of Washington/ Harborview Medical Center (HMC) , and with the Seattle Fire Department's Medic One program. Paramedics are trained to provide advanced emergency medical care to patients with serious or life threatening illness or injury. This pro- gram is one of the most advanced paza- medic trauung programs in the world. All paramedics in Seattle and King County receive nearly 3,�0 hours of training provided by leading physicians in emergency medicine, anatomy and physiology, pharmacology, and other subjects. There are currendy 20 paramedic units in the greater Seattle-King County re- gion, with six pazamedic units in Seattle and 14 units in the County (see Map 3). A paramedic unit is typically staffed by two paramedic� and requires approxi- mately nine paramedic FTE's (full time equivalent staf fl to provide service 24 hours per day, 365 days per year. All six pazamedic units in Seattle are staffed by two pazamedics at a time. However, the pazamedic program in the County in- cludes a wider variety of staffiag con- figurations in keeping witY► different geo- graphic and demographic patterns. Eleven pazamedic units in the County are staffed by two-paramedics at a time and operate 24 hours per day. In addi- tion, there are two EMT/paramedic (EMT/P) units staffed by an EMT/ firefighter and one paramedic. F1vfI'/1' units are deployed in the more ouflying areas of King County where response times for suburban-based units are typi- cally long. When necessary, these units are backed up by two-pazamedic units, and specific dispatch criteria exist to help send the additional paramedic unit whenever needed. These units currenfly respond to both BLS andALS responses. The County also operates two half-time ALS units, with an additional 12-hour unit planned for Southeast King County �,_� These units are staffed with two para- - medics at a time, operating 12-hours per day during peak workload periods. These units are effective in suburban az- eas which have rapidly growing workloads and long response times, but which have not yet grown busy enough to warrant a 24 hour unit. Over 60% of the workload occuning in a 24 hour , �I .� ; � 11 • period can be served by these units. When the 12 hour units are not in ser- vice, the nearest 24 hour pazaznedic unit covers their service area. In 1996, paramedics responded to 46,600 ALS calls in the region, of which 19,600 were in Seattle and 27,000 in the County. This represents about 35% of total EMS calls that yeaz: More importandy, this is a 10.1°� increase in paramedic calls over the 1992 call volume in the Seattle-King County region. The majority of the growth in AIS call volume occurred outside Seattle. Ex- cluding Seattle, other King County juris- dictions experienced a 23% increase in their ALS calls between 1992 and 19%. This growth occurred despite improve- ments to the County's ALS dispatch cri- teria. Without the unprovements, it is likely that the rate of increase in the County's ALS responses would have been greater than 23%. A summary of BLS andAlS utilization for the first five years of the current EMS levy is summa- rized in Table 1.1. Airlift Northwest is a not-for-profit air aznbulance service that provides AIS air transport to critically ill and injured pa- tients. Air transports are used primarily in situations where ground transport times are too long for seriously ill pa- tients. P�ivate Ambulance Services Private ambulance companies operating in King County employ over 300 Wash- ington state certified EMT's. Privately employed EMT's receive the same EMS training and continuing education as EMT/firefighters with the exception of on-going training and use of automatic external defibrillators. The primary role of private ambulance companies in the King County EMS system is BLS trans- portation. In 1996, private ambulance companies transported 45,000 BLS pa- tients in both Seattle and King County. Transport Services � All medical emergency calls to 9-1-1 cur- rently receive a BLS response and ap- proximately one-third receive anALS re- sponse as well. Not all calls, however, require a transport and if one is needed, there are varying methods employed throughout the county to accomplish this. Pazaznedic units transport patients whose conditions or circumstances re- quire advanced life support and stabili- zation from the field to the hospital. These patients frequ�tly need monitor- ing or continuing care en route because they are medically unstable. BLS transports are performed by either EMT's employed by private ambulance companies or by EMT/firefighters. As a local option, most jurisdictions use pri- vate ambulance companies for the ma- jority of their BIS transports. Histori- cally, private ambulance transport com- panies directly bill the patient or patienYs health insurance for services rendered. Some BLS agencies prefer to handle their BLS transports with exist ing resources. The decision to transport BLS patients by the fire service or to use private irans- port is based on a number of factors in- cluding: � fire department or fire district policy • medical necessity • availability of private ambulance services in the area • BLS unit availability • the time of day • weather • destination, particularly to hospitals outside their response area or juris- diction • availability of backup resources Regional Services Regional coordination of the county por- tion of the EMS system is administered through the EMS Division of the Seattle / ' �) ,j� ��I 12 � King County Department of Public Health. The Division is responsible for the following regional EMS functions: • Medical Program Director for the County • EMT and First Responder Basic Training, Continuing Education and Instructor Training • Emergency Medical Dispatch Guidelines and Triage Criteria Train- ing • Public Education • Emergency Pr�paredness • Critical Incident Str�ss Management • Quality Assurance/Quality Im- provement • Data Collection,Analysis, and Plan- ning • Paramedic Continuing Education • ALS and BLS Contract Administra- tion and Oversight forAlS and BLS Providers • General Administration and Coor- dination of the County's EMS Pro- Sr� • Administration, Allocation, and Oversight of EMS Levy Funds Cument Funding Mechanisms The County's EMS System is funded by a combination of EMS levy funds and other city and county taxes. State law allows jurisdictions to levy as much as $0.50 per $1,000 of assessed property values. For the last three levy periods, spanning 18 years, the levy rate in Se- attle and King County has not exceeded $.25 per $1,000 of assessed value. De- pending upon the growth in assessed valuations and the 106% levy lid, the actual levy rate has ranged from as low as $0.19 during the late 1970's up to the current rate of $0.25. InKing County, the EMS levy is a munty- wide levy and requires voter approval every six years. Voter turnout must ex- ceed 40% of the prior general election with an approval rate of 60% or greater. � Historically, voters have demonstrated strong support for the EMS system with approval rates exceeding 70%. State law requires the King County Council as well as local jurisdictions with populations in excess of 50,000 to ap- prove the levy proposal prior to place- ment on the ballot. Until recendy, Seattle and Bellewe were the only cities to meet this threshold. The County now has three additional cities required to ap- prove the ballot pmposal, including Fed- eral Way, Shoreline, and Kent. The County and the City of Seattle man- age their EMS levy funds in different ways. Seattle rnntributes its share of the EMS levy to the city's general fund and allocates moneys back to the fire depart- ment as an integrated budget package. Its share of the EMS levy is based on ac- tual funds collected from Seattle resi- dents and commercial properties. The EMS Division annually allocates EMS levy funds to the county's 35 BLS providers, four ALS providers, and re- Si°nal Programs. The EMS Division uses an allocation formula approved by the fire departments and fire districts for dis- tribution of BIS funds. This formula takes into consideration urban and ru- ral differences, as well as the population size, BLS call volume, and assessed prop- erty values in each fire department's ser- vice area. The BLS funding levels are cal- culated annually using this formula. EMS levy funding for paramedic ser- vices is provided annually to contracted ALS providers through a standard unit cost methodology. The standazd unit cost formula includes the annual aver- age cost of personnel, medical equip- ment and supplies, and support services such as dispatch, training, and medical direction. The average unit cost is ap- proximately $934,000 per pazamedic unit in 1997. ' �� ; 13 i • f � King County Department of Public Health. The Division is responsible for the following regional EMS functions: Historically, voters have demonstrated strong support for the EMS system with approval rates exceeding 70%. • Medical Program Director for the County • EMT and First Responder Basic Training, Continuing Education and Instructor Training � Emergency Medical Dispatch Guidelines and Triage Criteria Train- ing • Public Education • EmerSen�7' Preparedness � Critical Incident Stre.ss Management • Qualiry Assurance/Quality Im- provement • Data Collection, Analysis, and Plan- ning • Pazamedic Continuing Education • AIS and BLS Contract Administra- tion and Oversight forALS and BLS Providers • General Administration and Coor- dination of the County's EMS Pro- Sr� � Administration, Allocation, and Oversight of EMS Levy Funds Current Funding Mechaoisms The County's EMS System is funded by a combination of EMS levy funds and other city and county taxes. State law allows jurisdictions to levy as much as $0.50 per $1,000 of assessed property values. For the last three levy periods, spanning 18 years, the levy rate in Se- attle and King County has not exceeded $.25 per $1,000 of assessed value. De- pending upon the growth in assessed valuations and the 106% levy lid, the actual levy rate has ranged fram as low as $0.19 during the late 1970's up to the current rate of $0.25. In King County, the EMS levy is a county- wide levy and requires voter approval every six years. Voter tumout must ex- ceed 40% of the prior general election with an approval rate of 60% or greater. State law requires the King Counry Cou�ucil as well as local jurisdictions with populations in excess of 50,000 to ap- prove the levy prop�al prior to place- ment on theballo� Until recendy, Seattle and Bellevue were the only cities to meet this threshold. The County now has three additional cities required to ap- pmve the ballot proposal, including Fed- eral Way, Shoreline, and Ken�. The County and the City of Seattle man- age their EMS levy funds in different ways. Seattle rnntributes its share of �e EMS levy to the city's general fund and allocates moneys back to the fire depart- ment as an integrated budget package. Its share of the EMS levy is based an ao- tual funds collected from Seattle resi- dents and commercial properties• The EMS Division annually allocates EMS levy funds to the county's 35 BtS providers, four ALS pmviders, and re- Si��P�S='�. TheEMSDivisionuses an allocation formula appmved by the fire departments and fire districts for dis- tribution of BLS funds. This formula takes into consideration urban and nr ral differences, as well as the population size, BLS call volume, and assessed prop- erty values in each fire deparkment's ser- vice area. The BLS funding levels are cal- culated annually using this formula. EMS levy funding for pazamedic ser- vices is provided annually to contracted ALS providers through a standard unit cost methodology. The standazd unit -•_--- cost formula indudes the annual aver- age cost of personnel, medical equip- ment and supplies, and support services such as dispatch, training, and medical direction. The average unit cost is ap- proxunately $934,000 per pazamedic unit in 1997. �i � . ^ , � `1 I 13 � Funding for periodic replacement of paramedic vehicles is a major, ongoing capital cost. Vehicle replacement occurs on a regular basis and is currently funded separately from the standard unit cost. Start up costs for new paza- medic units cover personnel training, medical equipment and supplies, and other items. Start up costs are also funded apart from the standard unit cost. New AIS units are added whenever uti- lization exceeds capacity and/or re- sponse times exceed performance stan- dards. In addition to the EMS levy, ALS contractors contribute local funds to sup- port the indirect costs of paramedic services, or to enhance their paramedic prograzn to meet local community needs. BLS providers use local taxes to support the majority of their direct and indirect costs of BLS services. Fire departments represent a wide spectrum of communi- ties and vary in their ability to generate local revenue to support their BIS pro- grams. Throughout the current levy period (1992 -199�, increases in assessed prop- erty values have not maintained pace with the growth in the demand for EMS services and the added expense needed to serve this demand. Figure 1.1 demonstrates that the EMS levy dces not fund all activities for which the EMS Division is responsible. Other sources of revenues are needed, includ- ing County general funds, grants, and state contracts, as well as accumulated reserves. It is important to note that the difference between EMS levy revenues and the cost of EMS services is increas- ing. GLOBAL ASSUMPTIONS The current structure of the EMS system in King County is complex. There are facets of it that have proven effective, and which providers wish to maintain and • Figure 1.1 sso.o szs.o � = s2o.o � ; sis.o w o 510.0 c ss.o so.o ; �� . �� ,. ■7ota1 EMS Revames O EMS LevY Funds ■�s Note: EMS levy funds do not cove► EMS Division expenses. Additirnwl souices of ievenue such as county CX fu►uJs and grants a�e needed. The vuriance betu�em EMS costs and EMS leny m�mues has increased ovr► time. Total EMS reanues include accumulated reseraes. strengthen. This plan assumes the fol- lowing elements of the system will con- tinue, providing the basis of operations for 1998 - 2003. 1. The EMS System in King County will continue to function as a tiered response system. 2. King County EMS providers of BLS, ALS, and regional services remain committed to the current system and organizational structure of regional- ized prograzns. 3. EMS will continue as a public safety and public health program that functions collaboratively with other health care entities, both public and private. 4. The fire service will remain an inte- gral part of the tiered response sys- tem. 5. Advanced Life Support services will continue to be an essential public service, funded prunazily by tax dollazs. The global assumptions reflect a collec- tive commitment among the County's EMS providers to strengthen an EMS program that has proven successful 1992 —1997 EMS Revenues and E:penses 14 199Z 1993 1994 1995 1996 1997 � throughout neazly 20 yeazs of service. Collectively, EMS providers acknowl- edge that the benefits of regionalization, collaboration, and cross jurisdictional coordination far exceed the individual benefits associated with other EMS ser- vice delivery models and funding mechar►isms. Seattle and King County's EMS pro- grams have achieved cost savings and quality of service that is unpazalleled in other parts of the country. Recent surveys on public services in Seatde and Bellevue found that EMS services were rated first or second in importance and in con- sumer satisfaction. In response to strong consumer support, this strategic plan assumes continuation of a publicly funded EMS system and does not ex- plore other public or private service de- livery or funding mechanisms• ISSUES AND CONCERNS While there are many positive aspects of the County's EMS system, there are also service delivery and funding issues that need to be addressed, including growth in demand for EMS services, perceived use of the EMS system as a health sys- tem safety net, and funding lunitations for public services. Growth in Demand for EMS Services Citizens throughout King County are calling 9-1-1 for medical assistance at a rate that exceeds population growth or changing demographics. Population has grown approximately 1.1% per year since 1990 and the average age has in- creased by one year since the beginning of this levy period. The average annual rate of growth in EMS c.alls, however, has been 6.0% per year in the county. • Figu�e 1.2 S�ttle xing Crnu►ry Total Camty 1992 -1997 Compaiison ot Growth 11�eads Avenge Mnual Pement Change C� .�� <- ■ Total EMS Responses � �s catts per i000 I atian Growth Figure 1.2 oomperos historia+l growth tnnds in population, EMS calts, arul EMS callsl1,000 pvpulation. Table 1.1 HISTORICAL EMERGENCY MEDICAL RESPONSES Total EMS Calls Seattle King County Total Total ALS Calls Seattle King County Total 1992 1993 1994 1995 1996 43,764 48,111 48,162 50,064 52,737 62,272 68.643 71,288 79,504 81.107 106,036 116,754 119,450 129,568 133,844 20,404 20,823 18,873 18,339 19,609 21,951 23,036 24,119 26,882 27,005 42,355 43,859 42,992 45,221 46,614 Population (in 000's) Seattle 522 528 King County 1,043 1,060 Total 1,565 1,588 EMS Calls Per 1000 Population Seattle 84 91 King County 60 65 Total 68 74 ALS Calls per 1000 Population ��e 39 39 King County 21 22 Total 2� 28 531 533 535 1,068 1,081 1,094 1,600 1,614 1,629 91 94 99 67 74 74 75 80 82 36 34 37 23 25 25 27 28 29 Percmt of EMS Calls with ALS Response Seattle 46.6% 43.3% 39.2°k 36.6% 37.2°k King County 35.3�a 33.6% 33.8°k 33.8% 33.3% Total 39.9°� 37.6� 36.0% 34.9� 34.8% Note: Di�J'erences betra�ec►i Seattle and King County ALS response statistics are due to variations in ALS dispatch criteria; reant changes to dispatch criteria in Seattle following the County's earlier changes; and diJjnenc�s betsveen the demographics of population seraed. 15 0.0% 1.0% 2.0% 3.096 4.0% 5.0% 6.0% + � • throughout neazly 20 yeazs of service. Collectively, EMS providers acknowl- edge that the benefits of regionalization, collaborationr and cross jurisdictional coordination faz exceed the individual benef'its associated with other EMS ser- vice delivery models and funding mechanisms. Seattle and King County's EMS pro- grams have achieved cost savings and quality of service that is unpazalleled in other pazts of the country. Recent surveys on public services in Seattle and Bellevue found that EMS services were rated first or second in importance and in con- sumer satisfaction. In response to strong consumer support, this strategic plan assumes continuation of a publicly funded EMS system and does not ex- plore other public or private service de- livery or funding mechanisms. ISSUES AND CONCERNS While there are many positive aspects of the County's EMS system, there are also service delivery and funding issues that need to be addressed, including growth in demand for F.7vIS services, perceived use of the EMS system as a health sys- tem safety net, and funding limitations for public services. Growth in Demand for EMS Services Citizens throughout King County are calling 9-1-1 for medical assistance at a rate that exceeds population growth or changing demographics. Population has grown approximately 1.1% per year since 1990 and the average age has in- creased by one yeaz since the beginning of this levy period. The average annual rate of growth in EMS calls, however, has been 6.0% per year in the county. Figure 12 1992 —1997 C�pacison of Growth 1Yends Seattle x�►s��r Total Cuunty ■ Total EMS Respocsses ] EMS Calls per 1000 1 tim Growth Average Annual Peroent Change Figure 1.2 compares kistorical growth trends in population, EMS caUs, and EMS calls/1,000 population. Table 1.1 HISTORICAL ENIERQENCY MEDICAL RESRONSES Total EMS Calls Seattle King County Total Total ALS Calls Seattle King County Total 1992 1993 1994 1995 1996 43,764 48,111 48,162 50,064 52,737 62.272 68.b43 71.288 79,504 81.107 106,036 116,754 119,450 129,568 133,844 20.404 20,823 18,873 18,339 19,609 21,951 23,036 24,119 26,882 27,005 42,355 '13.859 42.992 45.221 46.b14 Population (in 000's) ' Seattle 522 528 King County 1,043 1,060 Total 1,565 1,588 EMS Calls Per 1000 Popnlation Seattle 84 91 King County 60 65 Total � 74 531 533 535 1,068 1,081 1,094 1,600 1,614 1,629 91 94 99 67 74 74 75 80 82 ALS Glls per 1000 PopulaHon Seattle 39 39 36 34 37 King County 21 22 _.-._23 25 .:25. - Total 27 28 27 28 29 Penent of EMS Glls with ALS Response Seattle 46.6°k 43.3°k 39.2°k 36.6°� 37.2% King County 35.3�0 33.6°k 33.8% 33.8°6 33.396 Total 39.9% 37.696 36.0% 34.9% 34.8% Note: DiJj'erences betu�ern Seattk and King County ALS response statistics are due to variations in ALS dispatch criteria; reant changes to dispatch criteria in Seattle following the County's �rlier changes; and difjerences betuxen the demographics of population served. 15 0.0% 1.0'16 2.0% 3.096 4A96 5.0% 6.096 • Extrapolation of current growth trends through the next levy period result in a projected call volume of 120,000 EMS calls in the county by 2003. This com- pares to 81;000 in 1996 (See Figure 1.3). Meeting the challenge of continued growth has come with associated costs to the EMS system. During the 1992 — 19971evy period, the EMS Division has increased the County's ALS capacity by two ALS units, two EMT/P units and three 12 hour units. Continuation of current service delivery methods and current ALS dispatch tri- age criteria would require four addi- ti�al AIS units to serve the projected increase in workloads. At issue is whether the cure�ent EMS levy rate will be sufficient to fund curne►it ser- vice requirements and continued ALS expansion. ENIS Providers' Roles and Responsibilities Recent growth in EMS calls may be due to: • overall changes in our health system • increased social problems, and/or • confusion about the roles and re- sponsibilities of EMS providers. For example, there is anecdotal evidence to suggest that the health care system it- self may contribute to overall growth in EMS calls. Explanations of this phenom- ena may include: • early hospital discharges; • increased use of outpatient proce- dures; • increased use of home health ser- vices; or • overall changes within the health care system. In addition, EMS providers are increas- ingly called to medical emergencies cre- . Figure 1.3 200.000 i�poo g 16oA� o i�o.000 °' izo�000 a iao.aoo � � eo,000 � bo.000 �°- .o.000 io,aoo Historical md Projected EMS Calls Assuming No Change in Cutra►t'Iiaids ' �� ; Figure 13 demonstiates the potentia! implications on EMS sm�ice volumes if cunmt population gromth trends and rates of increase in EMS aaUsl1.000 population continue. ated by social problems associated with substance abuse, domestic violence, and crime-related trauma. These calls may involve life threatening situations and most EMT's and pazamedics feel well prepared to handle the medical aspects of these calls. They may not, however, have immediate access to social service providers who are trained to handle the non-medical issues in these situations. Citizens may not be cleaz about differ- ences between the public role of the EMS system and the private role of their health plan and physician. While there is limited data to substantiate their ob- servations, manY Pazamedics and EMT's indicate that patients are increasingly confused about their health care benefits. For example: some residents may call 911 rather than schedule an appointment with a physician who is increasingly more difficult to see; and some patients may choose not to use the EMS system when they should for feaz of incurring co-payments or being denied coverage due to differ- ences between the patient's percep- tion of an emergency and definitions used by their health plans. 16 � � � � � � � � � � � � �J Citizens may also be unclear about EMS transport responsibilities. Due to con- cems over liability and risk issues, EMS pmviders are conservative in their trans- port decisions and many times transport to hospital emergency departments as a precautionary measure. This may lead to (1) higher costs for hospitals which are reimbursed less than the cost of care; and (2) higher costs to patients who are denied coverage by some health plans who retrospectively determine that the emerg�cy room visit did not meet their definition of an emergency. It may also result in less efficient use of EMS re- sources, particulazly for field responses �t��P�uya��t��h�- pitals and require long transport times when other equally appropriate and doser destinations are feasible. A major issue challenging EMS provid- ers is definition of its futune role within the imoader social and health system. Funding Issues Management of EMS levy funds has re- quired careful attention to current as well as projected service needs. Careful fi- nancial planning has historically been needed due to: the length of the levy period, cover- ing six years; the 106% levy lid which 1'units the annual increase in funding to 6% over the prior yeaz's funding level regardless of actual growth in the de- a►and for services; and variation in property valuation in- creases that may not match the growth in demand for service. It was projected in 1992 that excess fund balances during the eazly years of the levy period would be accumulated to cover expected deficits during the latter years when it was known that EMS costs would exceed revenues generated at the authorized levy rate of $0.250 per $1,000 av • ' �� ^ y f Figun 1.4 1992 -1997 Gsh Accumulationa Fmm All Funding Sources � 0 � � � a H � $8.0 $6.0 a4.0 $2.� $0.0 The current le�y 6udget for 1992-1997, has ban rvrU managed to assure that existing funding (EMS plus additional sourcesl covered each year's expcnscs. Although the 1996 authorized levy rate is set at $0.250 per $1,000 of assessed property values, the actual cost for EMS services in 19% required funding equal to $0.270 per $1,000. Accumulated re- serves together with non EMS levy funds have covered these anticipated increases in demand and cost for EMS services throughout the 1992-19971evy cycle. Figure 1.5 compares the annual rates of change in EMS call volume, expenses, and total revenues. Call volume in- Figun 1.5 i�-� 1995-6 1994-5 i�� i�z-: Annwl Pematage Inerease (Deaease) Comparison of Mnwl Percenhge Change in CaU Volume, Expenses,and Revenues ■Total Cab pEMS Gll� ■Total Fand� » � � � � � � -59G 096 596 109L 1596 20% 25% 30% 359� 40% 4596 �J Citizens may aLso be unclear about EMS transport responsibilities. Due to con- cerns over liability and risk issues, IIvIS providers are conservative in their trans- port decisions and many times transport to hospital emergency deparlments as a precautionary measure. This may lead to (1) higher costs for hospitaLs which are reimbursed less than the cost of care; and (2) higher costs to patients who are denied coverage by some health plans who retrospectively determine that the emergency room visit did not meet their defuution of an emergency. It may also result in less efficient use of EMS re- sotu+ces, particularly for field responses that are SeograPhicallY distant fram hos- pitaLs and require long transport times when other equally appropriate and closer destinations are feasible. A ma jor issue challenging EMS prnvid- ers is definition of its futune nvie witkin the broader social and heatth system. Funding Issu� Management of EMS levy funds has re- qu;red careful attenti� to cun�ent as weu as projected service needs. Careful fi- nancial planning has historically been needed due to: • the length of the levy period, cover- lrig SiX yeal'S; � the 106°fa levy lid which limits the annual increase in funding to 6% over the prior year's funding level regardless of actual growth in the de- mand for services; and • variation in property valuation in- creases that may not match the growth in demand for service. "�I .� ( Figure 1.4 1992 -1997 Gsh Accumulations Fmm A11 Funding Sourees m 0 � M /ti e H � v $8.0 $b.0 $4.0 $2.� yV.O The cunent (euy budget fur 1992-1997, has 6een saeU mawgal to assurr t/wt existing funding (EMS plus additional sounatsl caaered auk y�a*'s exPa+sa. Although the 1996 authorized levy rate is set at $0.250 per $1,000 of assessed property values, the actual cost for EMS services in 1996 required funding equal to $0.270 per $1,000. Accumulated re- serves together with non EIvLS levy funds have covered these anticipated increases in demand and cost for EMS services thmughout the 1992-19971evy cycle. Figure 1.5 compares the annual rates of change in EMS call volume, expenses, and total revenues. Call volume in- Figure 1S i�-� 1995-6 1994-5 1993� 1992-: It was projected in 1992 that excess fund balances during the eazly yeazs of the levy period would be accumulated to cover expected deficits during the latter years when it was known that EMS costs would exceed revenues generated at the authorized levy rate of $0.250 per $1,000 Av Annual Percentage lnaea�e (Deaeaset , Comparison of Mnuai Percentage Change in Gll Volua�e, Expenses,and Revennes K�i�a� o�s c�u. ■ Tofal Funds » � � � � � � -5% 096 5% 309L 15% 20% 25% 30% 35% 409� 457� � creased every year of the levy cycle and expenses increased in five of the six years. Revenues increased during the first three years then actually declined during the last three yeazs, underscor- ing the value of cash accumulations dur- ing the eazly years of this levy period. While some non-levy funds may be available, it is uncertain whether these funds are sustainable on an ongoing ba- sis or whether the EMS system can rely on non-levy funding sources. Funding will be a major challenge dur- ing the next Tevy cycle. The current levy rate will need to be increased in order to support the major components of the curre►it regional EMS system during the next six year levy period. EMS Research Excellent outcome data exists for trauma and cardiac arrest patients served by EMS providers. This data medically sup- ports current EMS response time stan- dazds, dispatch guidelines, allocation of resources, and general deployment of aid and medic units. Additional research is needed to document the effectiveness of eazly pre-hospital intervention for other medical conditions. As an international model in out-of-hos- pital care, King Counfiy EMS providers are challenged to secure sufficient funds for ongoing reseanch and development in Emergency Medical Semices. EMS Operational Improvements There are operational issues that need to be addressed during the next six years, including evaluaiion of: triage guidelines for dispatching ALS and BLS units; response time standazds that con- sider varying emergency situations; expansion of quality assurance ac- tivities to include continuous qual- ity improvement principles; C� BLS and ALS performance indica- tors; better efficiency measures; and technology improvements to en- hance service delivery in the field. At issue is whether there is funding to support development and implementa- tion of these critical operational im- provements within the fiime frame when potential bene,fits and cost-savings will be most needed. SUMMARY OF EMS ISSUES AND CONCERNS Analysis of utilization and financial trends demonstrate that the demand for EMS services has increased more rapidly than the funding base needed to support it. To assure that service delivery costs are aligned with available f unding, it will be necessary to develop and implea►ent a combination of cost-control strategies and demand management initiatives. It also may be necessary to access other revenue in addition to existing fur►ding sources. Efforts to align limited funding with op- erating expenses need to consider meth- ods of ineeting emerging community needs while finding ways to address funding challenges to the current system. Coordination and collaboration with other health care providers will be needed to assure EMS services continue to be delivered cost-effectively and effi- ciently. EMS providers will continue to be chal- lenged by competing demands for rev- enues. In the future, it may be necessary to establish funding priorities to assure that expenditures balance competing needs for systemwide unprovements versus continuation of existing services to meet growth in demand. � �� 18 ' �) � ` MAJOR STRATEGIC FOCUS With multiple and sometimes conflicting funding and program priorities facing EMS providers, the strategic and finan- cial plan for the 1998 - 2003 1evy period focuses on the following: In the face of limited fundin� County EMS providers will work together collaboratively and coordinate efforts urith other public and private social and health care entities to: 1. Address increasing workload vol- umes in BLS and ALS serr�ices; 2. Enhance existing programs and ser- vices to meet unmet community needs; and 3. Addriess emerging serr�ice detivery and financial chatknges. 19 � CHAP'TER TWO 1998 - 2003 STRATEGIC PLAN INITIATIVES EMS SYSTEM COMPONENTS The current levy period can be chazao- terized as a time of system expansions and strengthening of intemal relation- ships. Plans for the 1998 - 2003IIVIS levy period aze characterized as a tune to strengthen external relationships and build a bridge to the future. The Emerg�cy Medical Services system in King County will continue its tradi- tion as a public health and safety pro- gram. Structured as a tiered response system,Advanced Life Support services will continue to be provided by paza- medics who are trained and certified by the University of Washington. Basic Life Support services will continue to be pro- vided by Emergency Medical Techni- cian/fire fighters. ys essential public services, AIS ser- vices will be supported primarily by the EMS levy and BLS services will continue to be supported on an incremental basis by EMS levy and primarily funded through the fire service. The EMS Divi- sion will strengthen its role in coordinat- ing regional EMS activities, quality as- surance, and collaboration with other public and private health care entities. Field Medicine As a key access point into the broader health care systenn, EMS will play a small but critical role as part of the health care safety net. Its primary responsibility is � to provide emergency medical services in the field, referring non-emergent and prunary care calls to more appropriate providers. Universal Access The County EMS system will assure uni- versal access to EMS services through- out King County, taking into consider- ation the financial and operational practicalities of serving residents in the more remote and lesser populated azeas of the county. Quality As an internationally recognized re- gional model for Emergency Medical Services, the County EMS system will continue to deliver the highest quality service within available resources. En- hancement of quality assurance and quality improvement programs will be a primary focus during the ensuing levy period. Funding Direct costs for ALS services will be funded ihrough the EMS levy with an expectation that host agencies will ab- sorb indirect prograzn costs through fire service budgets, hospital funds, or county general funds (CX funds). As an incremental cost to the fire service, EMS levy allocations for BLS services will sup- port EMT training and continuing edu- cation, limited personnel costs, equip- ment purchases, and other related E1vI.S costs. ' �� l ��I 20 • Research The County EMS system will continue to support field medicine research in col- laboration with the University of Wash- ington School of Medicine, Hazborview Medical Center, and UWMC. Areas of analysis will expand beyond cazdiac az- rest and trauma to include other types of emergency services' outcome mea- sures. Collaboration The County EMS system will rnllaborate with other public and private health care @Tlhtles t0 minimi�.P the I'at2 Of glOWth in health care costs and to ensure con- tinued high quality patient care. Community Service As an essential community service, the County EMS system will provide service or assure access to more appropriate types of assistance to all in need regard- less of ability to pay and with due respect to cultural and ethnic diversity. Standards EMS providers will meet uniform stan- dards for ALS and BLS service delivery as defined by the Medical Program Di- rector, including standards on quality, minunum levels of service, data collec- tion and reporting, transport disposition guidelines, and other standards that pro- mote cost-effective and efficient EMS services. Pilot Projects The County EMS syst� will initiate pi- lot projects to evaluate the feasibility of system improvements prior to imple- mentation. Pilot studies will be used to evaluate intervention efforts, refinement of ALS triage guidelines, development of BLS quality and performance stan- dards, and dispatch screening. STRATEGIC INRIATIVES 1888 — 2003 Over the next six years, EMS providers will undertake a number of strategic ini- � tiatives to improve the County's EMS system and to assure it can deliver high quality services within available funds. Many of the initiatives are new to the EMS system and require coordination and cooperation across multiple jurisdic- tions as well as collaboration with non- EMS health care entities. STRATEGIC INITIATIVE �t1: Diminish the rate of growth in demand for EMS aervic�s to 3�6 growth per y�r. County BLS service volumes increased an average of 6% per yeaz and ALS ser- vices increased an average of 4.6% per year during the currnnt levy period. This rate of increase exceeds population growth and aging factors. Other vari- ables, such as general trends in our health and social service system, may also explain the rate of change. To accommodate this growth, the County has increased its ALS capacity this levy period from seven to 14 units. Develop- ment, installation and ongoing costs for a new pazamedic unit is a significant in- vestment. Methods need to be found to unprove management of the growth in pazamedic workloads and to reduce the need for additional ALS capacity in the future. There are three major approaches to diaunish continued increases in EMS calls for medical emergencies, including (1) public education (2) injury and illness prevention and (3) referral to other types of assistance when medically ap- propriate. Referral to other types of assistance may dimuush the need to expand the EMS system beyond which future resources may support. The 9-1-1 telephone sys- tem must reatain an open access point for all emergency calls. Some calls, however, do not require emergency AIS . or BIS response and, in the future, the EMS system may respond differently by C� .� �� , 21 � • Research The County EMS system will continue to support field medicine research in col- laboration with the University of i/Vash- ington School of Medicine, Hazborview Medical Center, and UWMC. Areas of analysis will expand beyond cardiac az- rest and trauma to include other types of emergency services' outcome mea- sures. Collaboration The County EMS system will rnllaborate with other public and private health care entities to m�*+�**+»� the rate of growth in health care costs and to ensure con- tinued high quality patient care. Community Serr�ice As an essential coaununity service, the County EMS system will provide service or assure access to more appropriate types of assistance to all in need regard- less of ability to pay and with due respect to cultural and ethnic diversity. StanAards EMS providers will meet uniform stan- dards for ALS and BLS service delivery as defined by the Medical Program Ui- rector, including standards on quality, minimum levels of service, data collec- tion and reporting, transport disposition guidelines, and other standards that pro- mote cost-effective and efficient EMS services. Pilof Projects The County EMS system will initiate pi- lot projects to evaluate the feasibility of system unprovements prior to unple- mentation. Pilot studies will be used to evaluate intervention efforts, ref'mement of ALS triage guidelines, development of BLS quality and performance stan- dazds, and dispatch screening. STRATEGIC INITIATIVES 1998 — 2003 Over the next six years, EMS providers will undertake a number of strategic ini- tiatives to unprove the County's EMS system and to assure it can deliver high quality services within available funds. Many of the initiatives are new to the EMS system and require coordination and cooperation across multiple jurisdio- tions as well as collaboration with non- EMS health care entities. STRATEGIC INITIATIVE 1N: Diminish the rate of growth in demand for EMS services to 396 growth P� Y� County BIS service volumes increased an average of 6% per year and ALS ser vices increased an average of 4.6% per year during the currei►t levy period. This rate of increase exceeds population growth and aging factors. Other vari- ables, such as general trends in our health and social service system, may aLso explain the rate of change. To accommodate this growth. the County has increased its ALS capacity this levy period from seven to 14 units. Develop- ment, installation and ongoing costs for a new pazamedic unit is a significant in- vestment. Methods need to be found to unprove managem�t of the growth in pazamedic workloads and to reduce the need for additional ALS capacity in the iuture. There aze three major approaches to dianinish continued inc7eases in EMS calls for medical emergencies, including (1) public education (2) injury and illness prevention and (3) referral to other types of assistance when medically ap- propriate. Referral to other types of assistance may dimuush the need to expand the EMS system beyond which future resources may support. The 9-1-1 telephone sys- tem must remain an open access point for all emergency calls. Some calls, however, do not require emergency ALS or BLS response and, in the future, the . EMS system may respond differenfly by �ci 1 . � -� f � ' 21 • expanding the types and levels of assis- tance available. Dispatch criteria and procedures will be revised to better match the appropriate response to the needs of the caller. This may include re- ferral to social and health services when appropriate or non-emergency response by a BIS agency. During the next levy period, the EMS system will pursue three major initia- tives to d'unnush the number of BLS and ALS responses while providing the pub- lic with appmpriate and effective assis- tance. The initiatives will be pursued through: coordination with the depaztment of public health and other providers on injury and illness prevention and intervention programs; revision of dispatch and care guide- lines to screen non-urgent calls for refeaal to social and health care ser vices when medically appropriate; and collaboration with local health plans and providers to educate the public on when it is appropriate to call 911 for assistance and to offer practical and easily accessible alternatives. STRATEGIC INITIATiVE # 2: Use E�cisting Resources More Efficiently Prajections indicate that four more AIS units may be needed in the county un- less existing resources can be utilized more efficiendy and the rate of growth in demand minimized. This poses a significant challenge to the County EMS system and the population it serves. To meet this challenge, EMS providers plan to: • modifyALS service delivery and re- source allocations; • revise and refine ALS dispatch tri- age guidelines; and � establish a broader array of transport destinations to shorten time and dis- tance factors for both BIS and some ALS calls. Such changes will be implemented in concert with a strong public information campaign to assure consumers and other health care providers are aware of the changes and are able to accommodate them. Specific prograzn changes to be explored and, if feasible, implemented include: (1) Revise and refine ALS dispatch triage criteria Paramedics indicate that current cri- teria-based dispatch guidelines au- tomatically call for their assistance on many calls where EMTs could handle the situation. To corroborate this, the EMS Division will study the feasibility of refining BIS and ALS triage guidelines to increase the fo- cus of ALS care on patients who will most benefit from AIS services. This will effect the scope of service ex- pected of BLS providers by expand- ing the number and types of BLS calls with ENTT/firefighters as sole responders. The EMS Division will work under the guidance of the Medical Program Director and with the assistance of other medical control physicians, paramedics and EM'T's to assure that modifications to the ALS triage guidelines meet patient care stan- dards and take into consideration the scope of practice and training requirements expected of EMT's. This study should be completed within the first yeaz of the levy pe- riod, allowing sufficient time during the second and / or third year to em- pirically test the validity of any dis- patch modifications prior to unple- mentation. � �) �f 22 r� � (2) Establish a broader array of transport destiriations A major component of the EMS sys- tem is transportation of the patient. Under curnent EMS guidelines, most transports are destined for hospital emergency rooms. This is medically appropriate for ALS transports which involve critically ill and se- verely injured patients. However, BLS transports involve patients whose conditions require medical at- tention, but not necessarily at the level of service and cost associated with hospital emergency depart- ments. The availability of a broader array of BLS transport destinations may reduce health care costs by treating patients closer to home and in more appropriate health care settings. It may aLso facilitate BLS pmviders' ca- pacity to expand the types of cases they see as sole responders, by di- minishing the number of long BLS transports. County EMS providers will continue discussions with local health plans and other healthcare providers on the feasibility of establishing non- hospital transport destinations for medically appropriabe EMS cases. In addition, it will be necessary to iden- tify and work with urgent care cen- ters and / or lazge medical groups interested in serving as IIvtS refer- ral centers. And finally, the EMS Di- vision will revise and refine dispatch guidelines and EMT/paramedic transport guidelines to implement this strategic initiative. (3) Coordinate with private hanspart com- p�anies As an integral component of the EMS system in King County, private transporters provide complemen- tary resources that support the EMS � system's responsibilities as an essen- tial public service. EMS providers are encouraged to continue working with private transporters to explore new opportunities to collectively meet the growing needs of the popu- lation and to establish a process to examine the most effective mle and relation5hip between public and pri- vate BLS transporters. (4) Rer�ise ALS per formance standards The EMS Division plans to revise performance standards for ALS units by increasing the annual utili- zation expected of each unit. Utili- zation of units varies from 600 — 3,200 calls per yeaz: Variatians in the utilization of County Medic Units are affected by current AIS service boundaries, S�S�Phic bazriers, dis- tance factors, and response time standards. Units operating 24 hours a day in urban settings average 3,000 calls per yeaz while EMT/P units op- erating in rural parts of the county average 550ALS calls per yeaz, in ad- dition to their BLS responsibilities. The 12-hour units began operation in December,1996, and are currently meeting expectations. Their utiliza- tion efficiency will be substantiated after one year. Recent expansion of ALS capacity this levy period allows reconfiguration of ALS service area boundaries. As service areas de- crease in size, it is feasible to increase the number of calls served by each unit per year. Higher utiliTZation together with con- tinuation of high quality services, requires extensive monitoring of call volume, response times, and other service indicators. The EMS Divi- sion has developed a monitoring systeni designed to track geographic changes in call volume and to mea- sure performance indicators which � c� ,� I 23 '�I ,�� , (2) Establish a broader array of transport destinations A major component of the EMS sys- tem is transportation of the patien� Under curnent EMS guidelines, most transports are destined for hospital emergency rooms. This is medically appropriate for ALS transports which involve critically ill and se- verely injured patients. However, BLS transports involve patients whose conditions requine medical at- tention, but not necessarily at the level of service and cost associated with hospital emergency depart- ments. The availability of a broader an�ay of BLS transport destinations may reduce health care costs by treating patients closer to home and in more appropriate health care settings. It may aLso facilitate BLS providers' ca- pacity to expand the types of cases they see as sole responders, by di- minishing the number of long BIS transports. County ENLSproviders will continue discussions with local health plans and other healthcare providers on the feasibility of establishing non- hospital transport destinations for medically appropriate EMS cases. In addition, it will be necessary to iden- tify and work with urg�t care cen- ters and/or lazge medical groups interested in serving as �EMS refer- ral centers. And finally, th� EMS Di- vision will revise and refine dispatch guidelines and EMT/paramedic transport guidelines to iaiplement this strategic initiative. (3) Coordinate with private transport com- panies As an integral component of the EMS system in King County, private transporters provide complemen- tary r�sources that support the EMS system's responsibilities as an essen- tial public service. EMS providers are encouraged to continue working with private transporters to explore new opportunities to collectively meet the growing needs of the popu- lation and to establish a process to examine the most effective mle and relationship between public and pri- vate BLS transporters. (4) Revise AIS perforn�ance star�dards The EMS Division plans to revise � performance standards for ALS units by increasing the annual utili- zation expected of each unit. Utili- zation of units varies from 6� - 3.200 calls per yea� Variations in the utilization of County Medic Units are affected by curnent ALS service boundaries, SeograPhic barriers, dis� . tance factors, and respoi►se time standards. Units operating 24 hours a day in urban settings average 3,000 calls per year while EM'T/P units op- erating in rural parts of the county average 550ALS calls per yea� in ad- dition to their BIS responsibilities. The 12-hour units began operation in December,l9%, and are currently meeting expectations. Their utiliza- tion efficiency will be substantiated after one yea� Recent expansion of ALS capacity this levy period allows reconfiguration of ALS service area boundaries. As service areas de- crease in size, it is feasible to increase the number of calls served by each unit per yeaz: Higher utili�ation together with rnn- tinuation of high quality services, requires exbensive monitoring of call volume, response times, and other service indicators. The EivlS Divi- sion has developed a monitoring syst�► designed to track geographic changes in call volume and to mea- sure performance indicators which � 23 � identify when to reallocate or rede- ploy resources, and/or realign ser- vice area boundaries. The EMS Di- vision will continue this monitoring system, working with EMS provid- ers to improve data collection and analysis capabilities, and to assure that utilization of existing resources is maximized. (5) Revise response time standasds for medi- cally appropriate caIls A new service delivery option for EMS may involve standards that dis- tinguish degree of urgency by type of call. The county's cunent re- sponse time standards are 4-6 min- utes for BLS and 10 minutes forALS. These standards are based an em- pirical research for cardiac arrest and trauma where there is medical evi- dence to support early medical in- tervention as a means to improve patient outcome; the eazlier the in- tervention, the better the outcome. Additional empirical research is needed to establish outcomes for early intervention among other medical illnesses or injuries. If re- sponse time standards can be length- ened or responses delayed for cer- tain types of cases without adversely unpacting patient outcomes, it may be possible to delay or minimize growth in ALS resources. During the first yeaz of the next levy period, the EMS Division undei di- rection of the Medical Program Di- rector, will undertake a pilot project to test the feasibility of varying re- sponse time standards for specific types of ca1Ls. (6) Explore alternative ALS unit schedul- ing options The EMS Division implem�ted two 12-hour pazamedic units this levy period and a third unit is authorized. n �� This scheduling option allows ALS capacity expansion to serve peak call periods without the cost of operat- ing a unit 24 hours a day. Future use of this or other scheduling options will be explored as needed through- out the next six years as a means to manage ALS costs and to increase utilization of euisting resources. Tuning to pursue the six prograzn op- tions is very important to successfully reduce the need for additionalALS units and to manage ALS costs. EMS pmvid- ers will develop and 'unplement program changes throughout the first three years of the levy period during which time there is projected to be sufficient capac- ity within the e�cisting system to absorb additional ALS call volume. By 2000 or 2001, demand is projected to exceed ex- isting capacity, requiruig that pmgrazn changes be in place. A two to three year implementation schedule assures that prospective pro- gram refinements can be thoroughly studied and evaluated prior to imple- mentation. It will aLso allow time for public education, dissemu►atian of pub- lic information, and development of injury and illness prevention and inter- vention services that support this chal- lenging effort. STRATEGIC INITIATIVE # 3 Enhance Existing Programs and Add New Programs to Meet Emerging Community Needs At this time, projected funding for EMS services in the County supports moder- ate enhancement of existing programs; pmvides limited funding to explore the feasibility of adding new programs; and allows evaluation of new programs through pilot projects. As a strategic ini- tiative of the next levy cycle, the EMS Division will move forward with pro- gram enhancements as funds become available. To expedite funding of new 1�.c1 � Lf►�. 24 � programs, the Division will collaborate with other private and public organiza- tions to address emerging conununity needs. Specific prograzn enhancements identified for the next six years include: (1) DfspaMher training it is a major priority during the next levy period to enhance dispatcher training. This is needed to revise ALS dispatch criteria, establish the infrastructure to refer appropriate 9- 1-1 calls to other types of assistance, and to promote a stronger and more uniform dispatch capability tluoughout the county. (2) Public Education Successful implementation of this strategic plan requires increased public awareness of proposed changes to the EMS system. Through enhanced public education efforts, EMS providers will: inform citizens about the appro- priate use of the 9-1-1 system; increase prevention and inter- vention activities; and identify other social and health organizations available for assis- tance. (3) Special Populations The EMS system will enhance its re- sponsiveness to special populations. EMS providers throughout the County are increasingly re- sponding to calls from people with English as a second lan- guage who may use the EMS system as an access point to pri- mary car� and other social ser- vices. The EMS system is in a position to educate such indi- viduals, as well as other citizens, #o the appropriate use of 9-1-1, � and to guide them to appropri- ate follow-up services. The EMS Division will work with the EMS providers and the Health De- partment to develop a set of bro- chures or other information packets that BLS providers can leave during the initial call, guiding patients to altemative services and follow-up care when appropriate. EMS providers are responding to an increasing number of hail patients. This will continue to grow due to an aging popula- tion, increased use of home health services, as well as con- tinued transition in the health care industry from inpatient to outpatient based services. In response, EMS providers will develop and initiate an interven- tion prograzn to reduce the need for emergency services before the need arises. As funds be- come available the EMS Divi- si� will pilot an intervention project in collaboration with other health caze entities and community services used by this segment of the population. (4) Corttinuous Quality Improvement The EMS Division will enhance its quality assurance activities through development of a uniform quality improvement prograzn to be imple- m�ted throughout the county EMS system. Funding for development, implementation and on-going man- agement of the enhanced pmgram will include a combination of EMS levy funds together with additional revenues. The EMS Division will explore the availability of grants, both public and private, to supple- ment levy revenues earmazked for quality unprovements. C� � �� 25 • . • . programs, the Division will collaborate with other private and public organiza- tions to address emerging community needs. Specific pmgram enhancements identified for the next six years include: !1) Dispatcher haining It is a major priority during the next � levy period to enhance dispatcher training. Tlus is needed to revise AIS dispatch criteria, establish the infrastructure to refer appropriate 9- 1-1 calls to other types of assistance, and to pmmote a stronger and more uniform dispatch capability throughout the county. (2) Puhlic Education Successful implementation of this strategic plan requires increased public awareness of proposed changes to the EMS system. Through enhanced public education efforts, EMS providers will: infornn citizens about �e appro- priate use of the 9-1-1 system; increase prevention and inter- vention activities; and identify other social and health organizations available for assis- tance. (3) Special Populations The EMS system will enhance its re- sponsiveness to special populations. EMS providers throughout the County are increasingly re- sponding to calls frem people with English as a second lan- guage who may use the EMS system as an access point to pri- mary care and other social ser- vices. The EMS system is in a position to educate such indi- viduals, as well as other citizens, to the appropriate use of 9-1-1, and to guide them to appropri- ate follow-up services. 'The EMS Division will work with the EMS providers and the Health De- partment to develop a set of bro- chures or other information packets that BLS pmviders can leave during the initial call, guiding patients to alternative services and follow-up care when appropriabe. . • EMS providers are respondin8 to an incneasing number of frail patients. This will continue to grow due to an aging popula- tion, increased use of home health services, as well as con- tinued transition in the health care industry from inpatient to outpatient based services• In response. EMS providers will develop and initiate aninberc►�r tion program to reduce the need for emergency services before the need arises. As funds be- come available the EMS Divi- sion will pilot an intervention project in collaboration with other health care entities and commsu►ity service.s used by this segment of the population. (4) Conrinuous Quality Improvement *. The EMS Division will enhance itis quality assurance activities through development of a uniform quality improvement program to be imple- mented throughout the rnunty EMS system. Funding for development, unplementation and on-going man- agement of the enhanced prograa► .., .._. will include a combination of EMS levy funds together with additional revenues. The EMS Division will explore the availability of grants, both public and private, to supple- ment levy revenues eazmazked for quality unprovements. C� ; j < �� 25 5� (5) Enhanced Research As funds become available, the EMS Division will explore the feasibility of collaborating with the Depart- ment of Public Health, health plans, hospitals, physician groups, and possibly the University of Washing- ton on longitudinal patient outcome studies. The focus of the effort is to establish an integrated database, in- duding information on pre-hospital, hospital, rehabilitation, and follow- up care. This data will support em- pirical research on the effectiveness of eazly medical intervention for conditions other than cazdiac anest and major trauma for which data already exist. STRATEGIC INITIATIVE �k4 Develop and Implement an EMS Advisory Committee The purpose of the EMSAdvisory Com- mittee is to assist the King County EMS Division to unplement the 1998 - 2003 EMS Strategic Plan. In its capacity as an advisory body, the Committee's prunary activities will include the following. The EMS Division will expand this list of ac- tivities as additional needs emerge. At a minimum the Coaunittee will advise on: • clinical perspectives from physicians on the committee regarding regional EMS issues; • operational issues related to EMS training, transport, communications, etc; • annual review and status update of the 1998 - 2003 EMS Strategic Plan PmBTess% • potential opportunities for new and creative funding initiatives; • EMS collaboration and coordination with other health care providers and health plans; and • periodic review of the EMS system financial status, including discussion C� of funding issues, options, and 'un- plications forALS, BLS and regional services. The Committee will meet regularly, but not less than four times each year, includ- ing a meeting each Spring where finan- cial forecasts and budgets for the upcom- ing yeaz are presented. This permits link- age with the EMSDivision'sbudget cycle each summer. In the event of major changes in service demands, pmgram re- quirements or other factors that may impact the EMS system and/or imple- mentation of this plan, the Committee will advise the EMS Division on pro- posed corrective actions. Membership of the Advisory Commit- tee will be broad based to assure repre- sentation of diverse constituencies within the Seattle and King County's EMS system. The Committee members will be appointed and confirmed by the EMS Division Manager and lunited to local EMS providers representing the following organizations: Physicians King County Medical Program Director, Seattle Medic One Medical Prograzn Di- rector, and Chair of the Medical Director's Group or his designee ALS Providers pne EMS representative from each ALS agency, including Bellevue Fire Depart- ment, Evergreen Hospital and Medical Center, Shoreline Fire Department, King County Medic One, and Seattle Fire De- partment. BLS Providers One EMS representative from each city over 50,000 population and not other- wise represented, to be selected by their fire department or fire department chief; one urban fire district provider to be se- lected by King County Commissioners; and one rural fire department provider to be selected by King County Commis- sioners. ��; j "� � I 26 C J Private Ambulance One EMS representative hom local pri- vate ambulance companies. Dispatch pne representative selected by the Dis- patch Centers. Labor One local BLS representative and one local ALS representative selected by the Washington State Council of Fire Fight- ers. Health Ptans One representative selected by the Health Plan and Provider workgroup. Regional Semices Manager of the EMS Division and agency staff as needed. Many program uutiatives need to be developed and implemented during 1997. The current EMS Strategic Plan Steering Committee will serve as an in- terim advisory committee to the EMS Division as it launches this strategic plan- ning effort. Current members, or their designees, will serve in this capacity through December,1997. POTENTIAL IMPLICATIONS OF THE 1998 - 2003 SYRATEGIC INITIATIVES Successful implementation of the 1998 - 2003 strategic initiatives is projected to reduce the potential growth in EMS call volume in the county from about 119,000 EMS calls to 107,000, a 10% reduction. It is estimated that refinements to the AIS dispatch triage criteria could reduce the percentage of EMS calls receiving an ALS response from 33% in 1997 to 30°10 by 2003. This is projected to reduce the number of potential ALS calls from 38,000 to 33,000 by 2003, a 13.3% reduc- tion (see Table 2.1). � The reduction inALS call volume is pro- jected to diminish the need for 2.5 - 3.0 ALS units by 2003. Strategic uutiatives intended to increase existing ALS unit capacity will further reduce the need for added AIS units in the future. ' �� Ta6le 2.1 PROJECTED EMS RESPONSES FOR UR(3ENT AND EMERGENT CARE County Sert�ices Only/Excludes Sea#le _ 12?� 1224 2444 Z441 Z4QZ Z4� COUNTY EMS RESPONSES No Change in Cur►ent Trends 92,285 Successful Implementation of Strategic Iratiatives 87,517 Potentiat Reduction in Coun EMS Call Volume �hrough Strategic Initiatives 4,768 97,162 101,396 107,931 113,326 119,165 91,110 94,832 98,823 102,959 107,264 6,052 6,564 9,108 10,367 11,901 COUNTY ALS RESPONSES No Change in Current Trrnds 30,425 31.767 32.909 34,893 36.460 38.104 Successfu! Implementation of Sriategic Initiatives 29,139 29,880 30,626 31,421 32,22Z 33,033 Potential Reduction in County ALS Cal! Vo[ume Through Strategic lnitiatives 1,286 1,887 2,283 3,472 4,238 5,071 27 • CHAPTER THREE 1998 - 2003 EMS FINANCIAL PLAN The six-year financial plan for King 6. County's EMS System is prea►ised upon a combination of prograzn and service initiatives to: control costs; 7 increase operating efficiencies; and manage the growth in demand for service. Additional assumptions include the fol- lowing. 1. 2. 3. 4. 5. The EMS levy needs to support con- tinuation of quality service and pro- vide adequate funding to develop strategic initiatives described in this plan. Funding decisions will be ap- proached from a system-wide per- spective. The financing plan recognizes indi- vidual jurisdictions' need for local autonomy to meet their communi- ties' expectations for EMS services. This financing plan depends upon coordination and collaboration be- tween EMS providers and other health care entities. The EMS Division is responsible for coordination and facilitation of col- laborative activities necessary to as- sure the success of this regional stra- tegic and financial plan. . As an essential public service, Ad- vanced Life Support services will continue to be supported prunarily by the EMS levy. As an essential public service, Basic Life Support services will be funded through a combination of local taxes that support fire services together with EMS levy funds to support the incremental cost of BLS. 8. New sources of revenue may be needed to fund enhancements to the EMS system which may include grants and other non-levy funds. CURRENT SOURCES OF FUNDING The County's EMS System is currently funded through a combination of local tax revenues including the county-wide EMS levy, local fire service coTtributions, ALS provider contributions, King County, and miscellaneous funding sources for special programs. The EMS Levy The primary source of funding for ALS services and regional programs is the EMS levy. BLS services are funded through a combination of EMS levy funds and local fire service funds. Au- thorized by state law, counties may levy up to $0.50 per $1,000 of assessed prop- erty values to finance their EMS system. Voters are asked to approve the EMS levy ' �) �� 28 � every six yeazs. In King County, voters have approved three county-wide six- year levies and will be asked to appmve the neact six-year levy during the Novem- ber,1997, general election. Unlike most special property tax levies, voters approve the F1vIS levyt�t�, rather than the amount of EMS funds. The rate sets the ENIS funding level during the first year of the six-year levy period. Funding during subsequent years is capped by the 106% levy lid or the levy rate, whichever is less. Under this fund- ing methodology, the levy lid will cap EMS funding levels if assessed proPertY values increase by more than 6% in any given yea� Otherwise, the levy rate will determine the maximum level of fund- ing available for EMS services• This methodology does not flexibly re- spond to growth in the demand for ser- vices or other community needs that af- fect the expense structure of the EMS system. As such, manaSement of EMS levy funds, monitoring of workload vo1- umes, and ongoing evaluation of perfor- mance standards throughout each six- year period is very important. The authorized EMS levy rate in King County has been $0.25 per $1,000 of as- sessed value for the last 12 years. This rate has provided sufficient revenues to expand the EMS system to meet histori- cal growth in the demand for services. Between 1992 and 1996, the rate of groH,th in EMS has exceeded the rate of growth in revenues. Cash reserves ac- cumulated eazly in the current levy pe- riod have made it possible to fund the EMS system and meet system demands through 1997 within existing revenues. Projections of future cost trends and fu- ture demand for EMS services will re- quire an increase in the EMS levy rate, taking into consideration initiatives to manage the rate of growth in services, and increased utilization of existing re- sources. Fire Service Contributions • A major source of financial support for the EMS system comes from the fire ser- vice through local tax contributions. In- tegration of BIS services into the fire ser- vice offers the public access to highly trained professionals committed to pub- lic health and safety at minunal cost. As an incremental cost to the fire service, the majority of EMT/firefighter salaries are funded through fire service budgets. Other public health and safety activities financed through the fire service include: • fire suppression • search and rescue • vehicle extrication • surface water rescue • disaster preparedness • hazardous materials response • life safety building code inspections • planning and administration • training and continuing education • injury and illness prevention Approximately 40% of EMS levy funds are cunently allocated to BLS�providers throughout King County. As an integral component of the County EMS system, BIS providers will continue to receive EMS levy funding to support their incre- mental costs of EMS services. ALS Provider Contributions Providers of ALS units contribute local support by absorbing into their other program budgets many ALS indirect overhead costs, including payroll, facili- ties, and administration costs. In 1997, ALS contractors contributed an average of 9% of total ALS unit costs. It is pro- jected within the 1998-2003 funding plan that ALS providers will continue to ab- sorb a portion of the indirect overhead costs. Otherwise, allowable ALS pro- gram costs will be funded by the EMS levy. ' �� ,�� 29 : • • every six yeazs. In King County, voters have approved three county-wide six- yeaz levies and will be asked to approve thenextsix-yeaz levy during the Novem- ber,1997, general election. Unlike most special property tax levies, voters approve the EMS levy �t�, rather than the amount of EMS funds. The rate sets the EMS funding level during the first yeaz of the six-yeaz levy period. Funding during subsequent years is capped by the 106% levy lid or the levy rate, whichever is less. Under this fund- ing methodology, the levy lid will cap EMS funding levels if assessed proPertY values increase by more than 6% in any given yeax Otherwise, the levy rate will determine the maximum level of fund- ing available for EMS services. This methodology does not flexibly re- spond to growth in the demand for ser- vices or other community needs that af- fect the expense structure of the EMS system. As such, management of EMS levy funds, monitoring of workload vo1- umes, and ongoing evaluadon of perfor- mance standards throughout each six- yeaz period is very importan� The authorized EMS levy rate in King County has been $0.25 per $1,000 of as- sessed value for the last 12 years. This rate has provided sufficient revenues to expand the EMS system to meet histori- cal growth in the demand for services. Between 1992 and 1996, the rate of growth in EMS has exceeded the rate of growth in revenues. Cash reserves ac- cumulated eazly in the current levy pe- riod have made it possible to fund the EMS system and meet systemdemands through 1997 within existing revenues. Pmjections of future cost trends and fu- ture demand for EMS services will r�- quire an increase in the EMS levy rate, taking into consideration initiatives to manage the rate of growth in services, and increased utilization of existing re- sources. Fire Service Contributions A major source of financial support for the EMS system comes from the fire ser- vice through local tax contributions. In- tegration of BLS services into the fire ser- vice offers the public access to highly trained professionals committed to pub- lic health and safety at minimal cost. As an incremental cost to the fire service, the majority of EMT/firefighter salaries are funded through fire service budgets. Other public health and safety activities financed through the fire service include: � fire suppression • search and rescue � vehicle extrication • surface water rescue • disaster preparedness • hazardous materials response � life safety building code inspections • planning and administration • training and continuing education • inlury and illness prevention Approximately 40% of EMS levy funds are currendy allocated to BlSproviders throughout King County. As an integral component of the County EMS system, BLS providers will continue to receive EMS levy funding to support their incre- mental costs of EMS services. , ALS Provider Cont�ibutions Providers of ALS units contribute local support by absorbing into their other program budgets many ALS indirect overhead costs, including payroll, facili- ties, and administration costs. In 1997, ALS contractors contributed an average of 9% of total ALS unit costs. It is pro-. ._.. ._. jected within the 1998-2003 funding plan that ALS providers will continue to ab- sorb a portion of the indirect overhead costs. Otherwise, allowable ALS pro- gram costs will be funded by the EMS levy. , �� , � � I �� 29 • Miscellaneous Funding The EMS Division receives limited fund- ing from a variety of sources, including the King County general fund for Divi- sion administration and overhead costs as well as grant funding to support spe- cific prograzns, including the following. • Seattle and King County trauma hospitals pmvide funding to support the Central Region Trauma Registry and to staff the Central Region EMS and Trauma Council; The State of Washington provides Seattle-King County with EMS and trauma funding for regional system development, training, major trauma registry maintenance, in- jury prevention, and other pro- granns. These funds are given to the Central region, overseen by the Re- gional EMS and Trauma Council, and administered by the EMS Di- Vision. • Local and federal grant funding is available to the Division for on-ga ing research in out-of-hospital field medicine, and the effectiveness of public education strategies. While minor in comparison to the EMS levy support, these adjunct sources of revenue allow the EMS Division the flex- ibility to collect and analyze data for ongoing quality assurance as well as planning and monitoring of the EMS system. Should the funding for these SP� P�Poses be eliminated, the EMS Division will need to locate alternate funding sources in order to maintain these activities. HISTORICAL FUNDS AND FUNDING ALLOCATION TRENDS Figure 3.1 illustrates the 1997 distribu- tion of revenues and expenses for EMS services. It is apparent that the EMS levy • Figure 3.1 81� 1997 EMS Revenues 3% 1696 pBeginning Balana ■ EMS Levy ■ Misc. Funds ■ ALS o sLs ■ Regional Sva ■ Other is the largest source of revenue and AIS services represent the largest cost com- ponent within the County EMS system. Growth in service demands and costs have increased more than growth in rev- enues. Planned eazly accumulation of cash reserves, shown in Figure 3.1 as "Beginning Balance" funds, have al- lowed the system to meet increased ser- vice demands without raising the levy rate. As shown in Tables 3.1 and 32, EMS levy funds increased only 4% per yeaz be- tween 1992 and 1997. At the sazne time, operating costs increased 12% per year, primarily due to substantial growth in call volume. The difference between EMS costs and EMS revenues is widening. While cash reserves and other sources of funding 46°6 C� ` � 1997 EMS E:peoses �� • , make up the d�fference ttus levy penod, it is cleaz that these will be insufficient through the next six yeazs at the current levy rate of $0.25. Financial analyses in- dicate that substantial reductions in the County's level of service and/or quality of care will occur if the EMS levy rate is not raised. ANNUAL LEVY RATE NEEDED TO COVER ACTUAL EMS EXPENSES Identifying the optimal EMS levy rate is very complex and requires consideration of multiple variables projected over a six year period. The rate must pmvide ad- equate funds each yeaz within the levy period, taking into consideration pro- jected growth in population, assessed property valuations, call volume and service considerations that may increase Costs. Table 3.3 illustrates what the EMS levy rate would have been if the EMS system was funded on an annual basis rather than a six yeaz levy period. The annual rates are derived by dividing actual EMS levy allocations (annual expenses) by annual assessed property values. The annual EMS levy rate to cover actual expenses ranged hom $0.222 in 1992 to $0.268 in 1997. Since the EMS levy is a six yeaz levy rather than an annual levy, the actual levy rate of $0.25 represents an average rate for the six year period. It is also important to note that the 1997 County EMS costs do not include a full yeaz of expenses for one new AIS unit to be operationalized some time in 1997. If the cost structure is adjusted to reflect a full yeaz of operation for this unit, then the EMS levy rate for 1997 would need t0 be $0.273. Table 3.1($ in thousands) HIS T O RICAL OPERATING COST TRENDS COUNTY EMS Average Annual 1�92 1� 1244 12� 122k 124Z �en8� AiS Seroices"' BLS Seruices R�Btonal Seroices Total EMS Divisivn � $5,884 $10,878 $9,337 $10,767 $11,798 $12,735 $6,522 $7,368 $7.707 $7,938 $8.017 $8,278 $1,279 $1,536 $2,163 $2,286 $2,610 $2,681 $13,685 $19,782 $19,207 $20,991 $?2,425 $23,694 19°k 4°� 18% 12% tl The historical cost hends reflect actual expenditures for each year. ln 1992, some ALS prvviders biUed the EMS Division in 1993 for services actualty delivered in 1992. The d'ffnence betwrrn the 2 yea►s is due to accaunting methods and does not indicate as la�ge of an increase in costs as might otheru�se be interpreted. Ta61e 3.2 ($ in thousands) HISTORICAL EMS DIVISION REVENUE TRENDS Average Annnual 19:�2 129� 19�4 124� 19� 124Z l�heu8� Beginning Fund Balance EMS Iray Revenue Other Revenues County CX Total Awtila6le Funds $2,850 $4,471 $5,716 56,433 $5,907 $3,977 $16,484 $17,886 $19,070 $19,609 $19,784 $20,397 4°k $274 $315 $587 $397 $297 $255 -1% $375 $375 $375 $375 $375 $375 0% $19,983 $23,047 $25,748 $26,814 $26,363 $25,004 4% 7% Ta61e 3.3 1992 -1997 LEVY RATE BASED ON ACTUAL EXPENSES Assessed EMS Levy Rate Needed te �q f Chax�e Valnation"' Expensesd To Cover Expenses I AV EMS (SSS in Millions) (3SS in Millions) Expensea 1992 1993 1994 1995 1996 1997 $104.450 $23.2 5317,809 a28.4 5118,222 527.3 5121,750 $29.8 $124,793 $31.9 So.222 50.241 so.�3i 50.245 $0.256 2% NA 13� 2296 <1% (4%) 3� 9% 3% 7% 1997 Adjusted 5127,913 $34.9 50.273 n, �a Values foi 1996 and 1997 an estimates n' Indudes Seattle's share of the EMS levy. r3' 1997 Adjusted: Reflects ful! ytar operating ex�enses if all 14 ALS units had 6een in operation for tu�elve months of the year. Three neu� half time units are scheduled for implementation throughout 1997. 31 � • , make up the difference this levy period Table 3.1($ in thousands) it is cleaz that these will be insufficient HISTORICAL OPERATING COST TRENDS COUNTY EMS ' through the next six years at the current Average levy rate of $0.25. Financial analyses in- Annual dicate that substantial reductions in the � � �q,qg � 129� L48Z % ChanQe County's level of service and/or quality A� of care will occur if the EMS levy rate is Servicestl $5,884 $10,878 $9,337 $10,767 $11,798 $12,735 19°k not raised. B� 8$7 707 $7 938 38 017 $8,278 4°� ANNUAL LEVY RATE NEEDED TO COVER ACTUAL EMS EXPENSES Identifying the optimal EMS levy rate is very complex and requires consideration of multiple variables projected over a six yeaz period. The rate must provide ad- equate funds each yeaz within the levy period, taking into consideration pra jected growth in population, assessed property valuations, call volume and service considerations that may increase COSt.S. Table 3.3 illustrates what the EMS levy rate would have been if the EMS system was funded on an annual basis rather than a six yeaz levy period. The annual rates are derived by dividing actuai EM.S levy allocations (annual expenses) by annual assessed property values. The annual EMS levy rate to cover actual expenses ranged from $0.222 in 1992 to $0.268 in 1997. Since the EMS levy is a six yeaz levy rather than an annual levy, the actual levy rate of $0.25 represents an average rate for the six year period. It is also important to note that the 1997 County EMS costs do not include a full yeaz of expenses for one new ALS unit to be operationalized some time in 1997. If the cost structure is adjuste�to reflect a full yeaz of operation for this unit, then the EMS levy rate for 1997 would need t0 be $0.273• Seroices $6.522 $7,36 . • • S� $1,279 $1S� $2.163 $2,286 $2.610 $2.681 18°� Total EMS Division Expenses $13,685 $19,782 $19,207 $20,991 $22,425 $23.b94 12% ru T� y�torica! cost trends reflect actual expenditures fior each year.ln 1992, some ALS providers 6illed the EMS Division in 1993 fior se►vices actuc+�ly delive►�a tn 1992. The d�erence beh,ueen the 2 yea►s is due to accounting methods and dces not indicate as la�ge of an incvease in costs as might otherwise be interpreted• Ta6le 3.2 ($ in thousands) HISTORICAL EMS OIVISION REVENUE TRENDS Avrrage Annnua! 1�22 1� 1254 19� 124� 122Z % ChanQe Beginning Fund Batance EMS. Ievy Revenue otne. Reuenues County CX Tota! Aaailable Funds $2,850 $4,471 55,716 $6,433 $5,907 $3,977 $16,484 $17,886 $19A7� $19,609 $19,784 $20,397 $274 $315 $587 $397 $297 $255 $375 $375 $375 $375 $375 $375 $19.983 $23.047 $25.748 $26.814 $26,363 $?5.004 7�0 4% -1% 0% 4% Ta61e 33 1992 —1997 LEVY RATE BASED ON ACTUAL EXPENSES psse8sed EIVIS Levy Rate Needed $gt• of Ctianve Valuation° ExpcnsesQ To Cover Expenses I AV EMS (SS$ in Millions) (SSS in Millions) �Pe�� 1992 $104,450 $�• 1993 $117,809 528.4 1994 $118,222 527.3 1995 $121,750 $29•8 1996 $124,793 331.9 �� 50.222 $0.241 $ti.23i ---- $0.245 $0.256 1997 Adjusted 5127,913 534.9 50.273 296 NA 13% 22% <1°6 (4%) ' - -- 3% 9°k 3% 7% 7% O Assessed Values for 1996 and 1997 are atimates a' Includes Seattle's share of the EMS levy. �" 1997 Adjusted: Reflects fuil yOa� %xrahn8 exPen�s if aU 14 ALS units had 6een in operation for turelve months vj the yu+r. Thm new half time units are scheduied fw implemmtation throughout 1997. 31 � FUTURE FUNDING RE�UIREMENTS ASSUMING NO CHANGE IN CURRENT TRENDS Initial financial projections identified a levy rate approaching $0.34 per $1,000 of assessed property values. This would be the rate needed to fund cunent ser- vices and future expansion assuming continuation of current growth trends and the addition of four ALS units to serve projected increases in call volume. It aLso assumes continuation of inflation- ary cost trends. Iri oTder to m�nimi�e tax iItCieases arid to reduce the percentage increase in the EMS levy, EMS providers will: • initiate cost-saving programs to re- duce the rate of increase in EMS costs; • increase operating efficiencies within existing resources; and • f urther enhance #he ability to deliver EMS services in the most cost-effec- tive manner. COST SAVING PROGRAMS The most sigiuficant cost saving strategy is to manage growth in demand for ser- vices as described in Strategic Initiative #2. This is expected to limit the number of additional ALS units to one unit dur- ing the next levy period. This is projected to save approxunately $3.0 million per year (in constant dollars.) This cost-sav- ing strategy allows 1998 and 1999 growth in ALS call volume to be served within existing capacity. If needed, one new ALS unit (or two new half-time units) may be added sometime in 2000 or 2001 depending upon growth trends and suc- cessful implementation of the 1998 - 2003 Strategic Initiatives. Other cost sav- ing programs included in this financial plan are: � development of a joint purchasing prograzn; �I • a five yeaz vehicle replacement, sal- vage, or retrofit program; • capping the number of pazamedic FI'E's to be funded through the EMS levy at nine per unit and a propor- iionate ratio thereof for EMT/P units and half time units; • expectingALS providers to fund ad- ministrative support and other AIS overhead through their other pro- gratn budgets; • indexing annual increases in ALS and BIS funding allocations to the Consumer Price Index. (Decisions on the applicable CPI rate wi11 be discussed by the EMS Division in concert with the EMS Advisory Committee on an annual basis.) The EMS Division will work with the EMSAdvisory Committee to explore and develop financial incentives that encour- age ALS and BLS providers to partici- pate in cost saving programs. EMS LEVY RATE 1998 - 2003 The cost saving mechanisms are pro- jected to decrease future EMS costs by 13.6%. While siguficant, these savings are insufficient to maintain current ser- vices with a levy rate of $0250. Further reductions in costs may result in degra- dation of service levels and quality of care may suffer. Financial projections indicate that a combinatiori of cost savi�gs and an in- crease in the EMS levy rate to $0.295 is needed to suqport this shategic plan through 2003. Revenue Assumptions Revenues to fund the EMS system are determined by assessed valuations and the levy rate. For the next six years, the King County Office of Management and Budget anticipates 2% per yeaz growth in assessed valuations of current prop- erties plus 2% per yeaz increases due to ��j �� - � u new construction. This results in a total of 4% per yeaz growth in assessed val- ues compounded over the six year time horizon. The financial plan assumes continuation of County CX funds at the 19971eve1 of $375,000 per year, accumulation of in- terest on unspent fund balances at 5% per yeaz, plus timber taxes and dona- tions. It is also assumed that the EMS Division will continue to receive grant fvnding for categorical pmgrazns. However, this rev- enue is excluded from the regional EMS system financial plan since elimination of grant support will end the special pro- grams unless other funding can be se- cured. The expenses associated with categorical programs are excluded from this financial plan as well. Projected Cost Assumptions EMS system costs are affected by call volume, population growth, resource utilization, inflation, and other factors. Prior to 2000, the financial plan assumes that EMS providers will expand utiliza- tion of existing resources to accommo- date continued growth in the demand for services. At the sazne time, it is assumed that EMS providers will work towards expanding and enhancing the cost-sav- ing programs. It is also projected that EMS providers will be successful in their collaborations with other health care en- tities to m;n;m»� the rate of growth in demand for EMS services and to broaden the azray of transport destinations avail- able throughout the county. The projected financial plans include funding to develop and implement the strategic initiatives, including funding to: • revise and refine dispatch triage guidelines for ALS responses; • expand and enhance ALS and BLS performance guidelines and contract standards; � develop data collection and report- ing systems to measure and assess the impact of strategic decisions on patient caze, quality and outcome measures; and develop a continuous quality im- provement program. The EMS system funding plan includes sufficient resources to develop pilot projects prior to full implementation of proposed strategic initiatives and pro- gram improvements. This will assure that operational changes achieve the de- sired results . The cost prajections also include one new AIS unit to be added in 2001, depend- ing on workload and other service indi- cators. The staffing model and schedul- ing option for this unit will be deter- nuned as service demands indicate. Pro- jected reductions in the number of new ALS units from four to one assumes that increases in ALS workload will be man- aged by: m;n;m»;ng the rate of growth in the demand for services, ongoing review and revision of ALS triage guidelines, and increased utilization of existing re- sources. Projacted Levy Rate for 1898 — 2003 Based on the financial assumptions plus successful implementation of the strate- gic initiatives and cost-saving programs, the EMS Strategic Plan Steering Conlmit- tee recommends that the EMS levy rate be increased to $0.295 per $1,000 of as- sessed property values. A combination of cost reductions, operational efficien- cies and increased revenues will allow EMS providers throughout the County to deliver the level and quality of service expected by the communities they serve. Table 3.4 illustrates the projected rev- enues and costs needed to support the County's EMS system through 2003. �' � 1 ,�� 33 � • new construction. This results in a total • develop data collection and report- of 4% per yeaz growth in assessed val- ing systems to measure and assess ues compounded over the six yeaz time the impact of strategic decisions on , horizon. patient care, quality and outcome measures; and The financial plan assumes continuation of County CX funds at the 19971eve1 of $375,000 per yeaz, accumulation of in- terest on unspent fund balances at 5% per yeaz, plus timber taxes and dona- tions. • develop a conhnuous quality im- provement program. The EMS system funding plan includes sufficient resources to develop pilot pmjects prior to full implementation of proposed strategic initiatives and pro- gram impmvements. This will assure that operational changes achieve the de- sired results . It is also assumed that the EMS Division will continue to receive grant funding for categorical prograzns. However, this rev- enue is excluded from the regional EMS system financial plan since elimination of grant support will end the special pro- grams unless other funding can be se- cured. The expenses associated with categorical programs are excluded from this financial plan as well. Projected Cost Assumptions EMS system costs are affected by call volume, population growth, resource utilization, inflation, and other factors. Prior to 2000, the financial plan assumes that EMS providers will expand utiliza- tion of existing resources to accomma date continued growth in the demand for services. At the same time, it is assumed that EMS providers will work towards expanding and enhancing the cost-sav- ing programs. It is also projected that EMS pmviders will be successful in their collaborations with other health care en- hti�S t0 IIli nimi�a the rate of growth in demand for EMS services and to broaden the array of transport destinations avail- able throughout the county. The projected financial plans include funding to develop and implement the strategic initiatives, including funding to: • revise and refine dispatch triage guidelines for ALS responses; • expand and enhance ALS and BLS performance guidelines and contract standazds; The cost projections also include one new AIS unit to be added in 2001, depend- ing on workload and other service indi- cators. The staffutg model and schedul- ing option for this unit will be deter- mined as service demands indicate. Pro- jected reductions in the number of new ALS units from four to one assumes that increases in ALS workload will be man- aged by: • minimizing the rate of growth in the demand for services, • ongoing review and revision of ALS triage guidelines, and • increased utilization of existing re- sources. ,- Projected Levy Rate for 1998 — 2003 Based on the financial assumptions plus successful unplementatian of the strate- gic initiatives and cost-saving prograzns, the EMS Strategic Plan Steering Coaunit- tee recommends that the EMS levy rate be increased to $0.295 per $1,000 of as- sessed property values. A combination .__ .__ of cost reductions, operational efficien- cies and increased revenues will allow EMS providers throughout the County to deliver the level and quality of service expected by the communities they serve. Table 3.4 illustrates the projected rev- enues and costs needed to support the County's EMS system through 2003. 33 � The EMS system will need additional revenue to maintain current services if the financial assumptions are not met. In the event of limited revenues or in- creased demand beyond that which is funded in this plan, EMS providers may need to reduce the level and quality of services delivered. The EMS Advisory Committee will develop consensus rec- ommendations about how and where proposed reductions may occur• NEW PROGRAM DEVELOPMENTS This funding plan recognizes that EMS funding will be limited during the next levy period. It is highly desirable, how- ever, to uutiate two new programs dur- ing the next levy period. The prograzns involve long term projects and will be pursued only if resources are available. The two major new projects include: (1) Dutcome Research 'The EMS Division intends to expand its research and planning system to measure and monitor patient out- comes in � types of urgent and emergent care, building upon the cunent cardiac anest surveillance program and the trauma registry. (2) Integrate data systems 'The EMS Division will continue its discussions with health plans and health care providers regarding de- velopment of a shared data system that integrates information on field medicine with hospital-based ser- vices. The EMS Division will pursue alterna- tive sources of funding to support these pmgrazn enhancements, which may in- clude: • government grants; • private foundation funds; • Figure 3.2 s3o,000 s2s,000 � � szo,000 � sis,000 � Sio,000 � v SSAoo ao � .. �l �y f � �w o�� p x�� s�..�. � sLS s�� ALS Saviees � � � � � � 8 � � � � Figu�e 3.3 1997 — 2003 Historical and Projected Sources of Revenue � � � � sss,000 s3o,000 s�s.000 szo,000 sis,000 sio,000 ss,000 ■ o� �as o �a�g � � � �r 34 King County EMS Historical aad Projected F�cponses � , , , . � � � � � � � � � 8 8 8 KING COUNTY EMERGENCY MEDICAL SERVICES HISTORICAL AND PROJECTED REVENUES AND EXPENSES Excludes Seattle EMS Levy Funds (1) (S in thousands) BEGINNING FUND BALANCE REVENUES EMS Levy - County Share Other Revenues (2) County CX Total County EMS Funds Total Available Funds (3) EXPENDITURES County AIS Services (4) County BLS Services Regional Services Strategic InitiaHves (5) Total County Expenditures REVENUES LESS EXPENDITURES Adjushnents (6) Ending Fund Balance Tuget Fund Balance l7) Historical Revenues and Expenses Levv Rate: 50.25 1992 1993 1994 1995 1996 1997 Budgeted $2.850 $4,471 $5,716 $6.433 $5.907 �3.977 $16,484 $17,886 $19,070 $19,609 $19,784 $20,397 �274 a315 $587 $397 $297 $255 1�375 a375 $375 �375 $375 5375 �17,133 $18,576 $20,032 $20,381 $20,456 $21,027 $19,983 523,047 $25,748 $26,814 a26,363 �25,004 $5,884 $10,878 $9,337 $6,522 $7,368 $7,707 $1,279 $1,536 $2,163 0 0 0 $13,685 $19,782 $19,207 36.298 �3.265 �6.541 ($1,827) $2,451 ($108) a4,471 $5,716 a6,433 $10,767 $11,798 $12,73! $7,938 $8.017 $8,27! $2,286 $2,610 $2,681 0 0 $6( $20,991 $22,425 $23,75! $5.823 $3,938 $1,25( $84 $39 $4( $5,907 $3,977 $1,29( $1,05] Projected Revenues and Expenses Levv Rate: $0.295 1999 2000 2001 2 y a- � w � 2003 �1,290 $1,383 $1,397 $1,758 $1,409 $1,493 $24,600 $25.600 $26,500 $26,100 $28.600 $29,800 $103 $110 $112 $143 $112 $119 $375 5375 $375 $375 $375 $375 $25,040 $26,044 $26,945 $26,618 $29,087 $30,294 $26,330 $27,427 $28,341 $28,376 $30,496 $31,787 $13,452 $14,310 $14,543 $14,577 $16,313 $17,149 $S.S00 $8,700 $9,000 $9,200 $9,500 $9,800 $2,500 $2,600 $2,700 $2,800 $2,800 $2,900 $495 $420 $340 $390 $390 $390 $24,947 $26,030 $26,583 $26,967 $29,003 $30,239 $1,383 $1,397 $1,758 $1,409 $1,493 $1,548 $1,383 $1,397 $1,758 $1,409 $1,493 $1,548 $1,522 1 Seattle leoy rev�enues and expenses are excluded from this ta6k due to dif�erent budget methods 2 Includes interest income on accumulated reservts � 5% plus very fimiteA amounts from designated tim6er taxes and public donations 3 Includes Revenues plus Beginning Fund Balance 4 Includes ALS contmcts, vehicle replacement, rural ALS sernices, new ALS unit start-up junds 5 See Table 3.5 for detailal budget 6 Adjustments reflect County Council designated reappropriations, encum6rances, and misc. 6udget adjustments 7 The King County Executive requires a S�o reserve at the close of each levy cycle �'n' � s. � � �� T K1NG COUNTY EMERGENCY MEDICAL SERVICES NISTORICAL AND PROJEC?ED REVENUES AND EXPENSES Excludes Seattle EMS i.evy Funds (1) ($ in thousands) Historical Revenues and Expenses �� BEGINNING FUND BALANCE REVENUES � EMS Levy - County Share Other Revenues (2) County CX Total County EMS Funds Total Available Funds (3) EXPENDITURES County ALS Services (4) County BLS Services Regional Services Strategic InitiaHves (5) Tohal County Expenditures REVENUES LESS EXPENDITURES Adjustments (6) Ending Fund Balance 1992 1993 1994 1995 1996 1997 Budgeted �2,850 $4,471 $5,716 $6,433 $5,907 a3,977 $16,484 $17,886 $19,070 $19,609 $19,784 $20,397 �274 $315 $5S7 �397 $297 $255 $375 $375 $375 $375 $375 $375 $17,133 $18,576 $20,032 $20,381 $20,456 $2I,027 $19,983 $23,047 $25.748 �26,814 $26,363 $25,004 Projected Revenues and Expenses Levv Rate: $0.295 1999 2000 2001 2002 � a- n w � �1,290 $1,383 $1,397 $1,758 $1,409 $1,493 , $24,600 $25,600 $26,500 $26,100 $28,600 $29,800 $103 $I10 $112 $143 $112 $119 $375 $375 $375 $375 $375 $375 $25,040 $26,044 $26,945 $26,618 $29,087 $30,294 $26,330 $27,427 $28,341 $28,376 $30,496 $31,787 $5,884 $10,878 $9,337 $10,767 $11,798 $12,735 $13,452 $6,522 $7,368 57.707 $7,938 a8.017 $8,278 $S,.ri00 51,279 $1,536 $2,163 $2,286 $2,610 $2,681 $2,500 0 0 0 0 0 a60 �495 60 �13,685 $19,782 $19,207 $20,991 $22,425 $23,754 $24,947 �6,298 $3.265 36,541 $5,823 �3,938 $1,Z50 �1,383 ($1,82� $2,451 ($108) S84 339 a40 $4,471 $5,716 36,433 $5,907 �3.977 $1,290 $1,383 � $14,310 $8,700 $2,600 $420 526,030 $1,397 $1,397 Target Fund Balance (7) ^ �1,051 ; 1 Seattle leny revrnues anA expenses are excluded fiom this table due to different budget methods 2 Includes interest income on accumulated reserves � 596 plus very limited amounts from designatul timber taxes and pu6lic dortatinns 3 lncludes Revenues plus Beginning Fund Balance 4 lncludes ALS contmcts, rxhicle replacement, ru�al ALS scrvices, new ALS unit start-up junds 5 See Table 3.5 fo� detailed 6udget 6 Adjustments ref[ect County Council designated reappropriations, encumbrances, and misc. 6udget adjustments 7 The King County Executive �equires a 59'o reserrx at the close of each levy cycle � � 1 $14,543 $14,577 $16,313 $17,149 $9.000 $9,200 $9,500 $9,800 $2,700 $2,800 $2,800 $2,900 $340 $390 $390 $390 $26,583 $26,967 $29,003 $30,239 $1,758 $1,409 $1,493 $1,548 $1,758 �1,409 $1,493 $1,548 �1,522 , , -�.=`-^- < � • contributions from potential data sharing partners; and/or • other public sources that may present themselves through the course of the 1998 - 2003 1evy period. It is anticipated that existing sources of EMS funding will be needed to support current services. However, it is possible that existing sources of funding may be available on a limited basis to support these new program developments. ALS FUNDING The EMS Division contracts with Bellewe and Shoreline Fire Deparlments and Evergreen Hospital to provide ALS services in North and Northeast King County. The Division providesAlS ser- vices in South King County. Funds are allocated to each ALS provider on a "Standard Unit Cost" basis. Budget items within the Standard Unit Cost cover all direct expenses and most indi- rect costs associated with the program. Allowable ALS expenses include: Personnel Pazamedic wages including continuing education Overtime pay, uniforms, and safety equipment genefitsBased on a percentage of wages which varies by sponsor Supplies lviedical, office, and vehicle supplies Support Services Utilities, rent, administrative staffing (Ivi$O's), paramedic student train- ing, travel, and dispatch costs � U A comparison of expenses across AIS providers indicates there is great suni- larity in the total cost of operating anAIS unit. Differences are due to variation in labor contracts or staffing nwc• Some ALS providers employ paramedics who are cross trained in the fire service, al- lowing greater administrative flexibility in the event of illness, vacation leave, dis- ability, etc. Analysis also demonstrates that the cur- rent standazd unit cost formula is equi- table and assures consistency across ju- risdictions in the type and level of ALS services delivered. The total cost per unit averages about $1.0 million per year. 'This is about 9% more than the funding provided through the standazd unit cost formula. ALS providers absorb the in- cremental expense within their other prograzn budgets. During the 1998-2003 levy period, the sazne standard unit cost allocation for- mula will be used to allocate EMS levy funds forALS services. This will include funding for nine pazamedic FTE's per ALS unit and other direct costs. As a budget control measure, ALS providers will be expected to continue absorbing a portion of indirect overhead costs. Beginning in 1998, the EMS Division will budget levy funds in support of EMT/P units and half time units up to half the standard unit cost for a 24 hour, 2 para- medic unit. BLS FUNDING Throughout the 18 yeaz history of the EMS levy, KinB County BIS providers have shared in EMS levy revenues. This funding policy reflects the County's long standing philosophy that EMS is a pub- licly-funded system based on collabora- tion and teaznwork betweenALS provid- ers, BIS providers, and regional services. Equipment &Maintenance Vehicle maintenance, communications, medical equipment, and office equipment Other Professional services, paz'amedic replace- ment, miscellaneous expenses• As an integral participant in this system, fire-service based providers of BLS ser- : �� j � , �I 36 � vices require resources and training to continue to deliver quality out-of-hospi- tal emergency patient care. A portion of EMS levy funds are allocated to BLS pro- viders to support these incremental ac- tivities. To assure there is stable BLS funding through 2003, financial support for BLS services from the EMS levy will be main- tained at current levels, adjusted annu- ally for inflation as measured by the CPI. This will assure county residents con- tinue to receive the quality and standard of care now delivered, and thatAlS pro- viders receive the level and quality of support expected of their BIS counter- parts. This financial plan acknowledges that AIS funding has priority over other EMS services. The plan also recognizes that BLS services contribute extensively to the success of the EMS system. Through- out the next levy period, it will be the responsibility of the EMS Division, in concert with the EMSAdvisory Commit- tee, to assure that EMS funding decisions reflect system-wide needs. If necessary, funding recoa►mendations will be presented to the King County Executive and King County Council for approval. BLS FUNDING FORMULA Financial analysis indicates that the cur- rer�t formula used to allocate BLS funds from the EMS levy to individual BLS pmviders is equitable and assures sta- bility over time. This formula will con- tinue to be used through the next levy period. The current BLS funding formula is based on three variables: assessed prop- erty values, population, and call vol- umes. �J Assessed valuation reflects the amount of tax dollars collected in each jurisdiction from the EMS levy; Changes in population allows for fluctuations attributed to growth patterns that naturally occur over time; and Call volume measures the actual use of EMS resources. EMS levy funds available for BLS are divided equally into three pools, one for each variable. The funds are then dis- tributed on a percentage basis to each BIS ag�cy. The three distributions are added together to derive each jurisdiction's individual BLS allocation. BLS allocations are adjusted to reflect changes in jurisdictional boundaries due to annexations, incorporations of new cities, or changes in service contract az- rangements. Stable funding is unportant to all EMS providers. To stabilize funds allocated to individual BLS agencies, the EMS levy allocation formula assures that no agency receives less in any given year than was received in the prior yeaz, ex- cept in the case of annexations and/or incorporations. In the event that total BLS funding is decreased, then all BIS providers will proportionately share in the decrease by applying the allocation formula to the lower amount of available funds. REGIONAL SERVICES FUNDING The roles and responsibilities of the EMS Division have grown over the last eigh- teen years in concert with the evolution of the EMS system in King County. Over time, the Division has accepted increas- ing responsibility for coordinating joint efforts to provide uniform training, dis- patch, medical control, and planning across 35 BIS providers and four ALS providers. C� , ��( ; 37 � vices require resources and trauung to continue to deliver quality out-of-hospi- tal emergency patient care. A portion of EMS levy funds are allocated to BLS pr�- viders to support these incremental ac- tivities. To assure there is stable BLS funding through 2003, financial support for BLS services from the EMS levy will be main- tained at current levels, adjusted annu- ally for inflation as measured by the CPI. This will assure county residents con- tinue to receive the quality and standard of care now delivered, and thatAlS pro- viders receive the level and quality of support expected of their BIS counter- P�• This financial plan acknowledges that ALS funding has priority over other EMS services. The plan aLso recognizes that BIS services contribute extensively to the success of the EMS system. Through- out the next levy period, it will be the responsibility of the EMS Division, in concert with the EMSAdvisory Commit- tee, to assure that EMS funding decisions reflect system-wide needs. If necessary, funding recommendations will be presented to the King County Executive and King County Council for approval. BLS FUNDING FORMULA Financial analysis indicates that the cur- rent formula used to allocate BLS funds from the EMS levy to individual BLS providers is equitable and assures sta- bility over time. This form�a will con- tinue to be used through the next levy period. The current BLS funding formula is based on three variables: assessed prop- erty values, population, and call vol- umes. Assessed valuation reflects the amount of tax dollazs collected in each jurisdiction from the EMS levy; Changes in population allows for fluctuations attributed to growth patterns that naturally occur over time; and Call volume measures the actual use of EMS resources• EMS levy funds available for BLS are divided equally into three Pools� one for each variable. The funds are then dis- tributed on a percentage basis to each BLS agency. Tl1e three distributions are added together to derive each jurisdiction's individual BLS allocation. BLS allocations are adjusted to reflect changes in jurisdictional boundaries due to annexations, incorporations of new cities, or changes in service contract az- rangements. Stable funding is important to all EMS providers. To stabilize funds allocated to individual BLS agencies, the EMS le�'Y allocation formula assures that no agency receives less in any given Year than was received in the prior year, ex- cept in the case of annexations and/or incorporations. In the event that total BLS funding is decreased, then all BLS providers will proportionately share.in the decrease by applying the allocation formula to the lower amount of available funds. REGIONAL SERVICES FUNDINC The roles and responsibilities of the EMS Division have grown over the last eigh- teen years in concert with the evolution --.,.. of the EMS system in King County. Over time, the Division has accepted increas- ing responsibility for coordinating joint efforts to provide uniform training, dis- patch, medical control, and planning across 35 BLS providers and four ALS providers. '�I .1< S � 37 * The EMS levy currently funds $2.8 mil- lion to support regional services. The Division also receives EMS levy funds based on the standard unit cost formula to support its ALS prograzn in South King County. As part of this financial plan, the Division's ALS funds are sepa- rated from funds that support regional services. The EMS levy funds for regional services are aggregated with a portion of county general funds to support the EMS Division's regional EMS responsibilities. In the past, some of these responsibili- ties supported Department of Health ac- tivities and other county functions not related to the IIviS system. The finan- cial plan for 1998 - 2003 changes the ivnding mechanism for non-EMS system activities provided by or through the EMS Division. Core Regional Functions In the future, EMS levy funds will be de- voted to core regional functions. Table 3.5 outlines the EMS Division's core ser- vices that are mandated by state law or county ordinance and which will be funded through the 1998-2003 EMS levy. The EMS Division is legally authorized to perform these activities and fvnd their operation through levy revenues. � Regional Services 1998 Program Changes A recent review of intemal EMS Division operations identified potential cost sav- ing opportunities through: • consolidation of certain programs with other health department func- tions; • transfer of program responsibilities to extemal agencies providing simi- lar services; and • transfer of funding responsibilities for non-EMS system activities to other health department budgets. The consolidations and transfers are pro- jected to save $195,000 in EMS Division costs. Recent reorganization and consolidation of services between the EMS Division and the King County Health Depar�nent allows the possibility for further cost- savings through integration of other pro- grams, 'The EMS Division Manager will continue to explore opportunities for shared savings. Catego�ical Progrems The Division currently administers about $183,500 in grant fundinS fro�► the State of Washington to the Seattle-King County region in support of trauma training and other activities related to the statewide trauma initiative. Grant fund- ing for categorical programs is not in- cluded in this financial plan, nor are the associated costs. If this graz►t fundin8 is decreased or discontinued, the services will be modified to reflect the level of available support. The Division aLso receives funding from the County general fund of $375,000 per year. This financial plan assumes that this level of county funding will be con- tinued during the next levy period to support indirect/overhead costs for the pLS program and other county admin- istrative activities that support regional EMS programs. It is also assumed that the Division will contitiue to generate interest income on cash reserves at an annual rate of 5%. UMunded Regional Programs The EMS system's response to public sentiment on new taxes resulted in a de- cision to not fund two new programs or initiatives through EMS levy funds. In- stead, it is recommended that funding ��i �� 38 . � u be sought through other sources as the oppominity arises. (1) Heaith plan coordination and collabora- tion Preliminary discussions with local health plan representatives and managed caze providers are under- way and will continue through the beginning of the next levy period. The discussions are focused on cost saving opportunities through pub- lic education, flexible transport des- tinations, and utilization manage- ment. Additional areas of focus for EMS and other health care provid- ers include improved quality of care and an enhanced continuum of care. The EMS Division will explore the feasibility of developing a public/ private parinership to fund continu- ation of these vital discussions and potential future collaborative efforts. EMS levy funds for implementing Strategic Initiatives #1 and #2 in- clude limited support for joint pub- lic/private discussions on EMS policy issues and feasibility studies. Additional funding will be needed to implement any policies that result from these discussions. (2) Enhanced Research Funding is not included in this finan- cial plan for an integrated database that includes patient information from pre-hospital, hospital, rehabili- tation, and follow-up care. Through the next levy period, the EMS Divi- sion will explore the feasibility of col- laborating with other providers within the full continuum of care to identify potential funding to support this effort. STRATEGIC INITIATIVES FUNDING PLAN • EMS levy funds have been earmarked for implementation of the 1998-2003 strategic initiatives. Funds will be needed to: explore the feasibility of proposed enhancements; evaluate program changes through pilot projects; and collaborate with non-EMS entities. Potential cost estimates to support the planning, development and 'unplemen- tation process are described in Chapter 4. In total, the funding plan earmarks $2.3 million dollars for implementation. �l �f Table 3.5 CORE REGIONAL FUNCTIONS SUPPORTED BY THE 1998 - 2003 EMS LEVY �. ,K,�� 1. Medical Program Director 2. EMT & First Responder Basic Trauung, CE Plus Instructor Training 3. Emergency Medical Dispatch 4. Critical Inddent Stress 5. Quality Assurance 6. Database 7. Pazamedic CE 8. Administration ,,�. mandated by state law cost effectiveness unifora►ity consistency across jurisdictions adjust ALS/BLS triage guidelines, control demand trauting unifomuty, rnnsistenc}, & cost effectiveness very successful for EMS low cost peer volunteers evaluation of AIS, BLS, & dispatch supports on-going planning, operations, and quality assurance complements HMC proSram necessary to meet recertificahon requirements ALS and BLS contract negotiation, monitoring and oversight regional EMS coordination acavities EMS advisory committee 39 L� CHAP'TER FOUR IMPLEMENTATION PLAN The 1998 - 2003 EMS Strategic Plan is a very ambitious undertaking. Implemen- tation will involve a series of critical de- cisions, many requiring time for detailed feasibility analysis, collaborative discus- sions, interagency coordination and, in many cases, pilot projects to assure that changes to the current EMS system will produce the intended benefits. The following discussion provides a roadmap for guiding the EMS Division and the EMS Advisory Committee through the implementation process. It sets priorities, identifies who needs to be involved and establishes critical anile- stones that must be met to achieve the 1998 - 2003 strategic and financial goals. The implementation plan is organized by year and builds upon the extensive work already initiated by the EMS Division and the EMS Strategic Plan Steering Committee. Durir►g lransition to the new levy period, the Committee will cantinue to assist the Division in this effort. 1997 In prepazation for the next levy period, the EMS Division and the EMS Strategic Plan Steering Committee will move for- ward with two major actions during the latter half of 1997. The first involves es- tablishment of the EMS Advisory Com- mittee. � 1. The EMS Advisvey Committee will provide valuable assistance to the EMS Division as it carries the EMS Strategic Plan fonvard. To expedite the implemen- tation process, it will be important that the Advisory Committee be in place by january,1998. Development of the Advisory Commit- tee requires completion of four actions by December,1997: • Develop membership criteria, estab- lish an appointment/confirmation process, and determine the length of term; • Solicit a list of candidates for Com- mittee membership, as defined in Chapter Three of this Plan; • Appoint/confirm EMS Advisory Committee members; and � Review the Division's workplan which detaiLs major work elements to be achieved and identifies how strategic objectives will be moni- tored. This workplan will summa- rize the major goaLs of the six year levy, and detail specific activities for 1998. Manager of the EMS Division, or his des- ignee, will be responsible for assuring these tasks are completed. 2. The second major initiative to be started during 1997 is to enhance re- gional cost saving programs. Funding limitations requi�e that BLS and ALS providers as well as regional services C � �� 40 � monitor and reduce costs whereverqos- sible. To assist in this effort, regional costsavingprograms should be initiated early in the levy period to maximize po- tential benefits. As a transitional advisory committee, the EMS Strategic Plan Steering Comiriittee will work with the EMS Division to de- velop and implement the following cost saving programs: A regional joint purchasing program for medical and office supplies will be developed, allowing EMS provid- ers access to better purchasing dis- counts than might be available to in- dividual agencies. Planning and de- velopment will be started during 1997 for full implementation first quarter,1998. The feasibility of a new vehicle re- placement, salvage, and retrofit pro- grazn will be studied during 1997. The goal of this program is to extend the useful life of paramedic vehicles to as much as five years by: - purchasing heavier chassis with longer useful lives; - replacing chassis periodically rather than entire vehicles; and / or - recouping some of the cost through resells at the end of their useful lives. The EMS Division needs a mecha- nism to monitor strategic and finan- cial performance throughout the next levy period. During 1997, the Division will enhance its monitoring database and work with BLS and ALS pmviders to assure that data are collected and reported in a timely manner. The EMS Division will work with the interun EMS Advi- sory Committee to develop mea- sures for monitoring contract perfor- mance, utilization levels, funding re- quirements, and cost-savings. • Participation in regional cost reduc- tion programs and performance monitoring processes is very impor- tant to the success of the 1998 - 2003 Strategic Plan. The EMS Strategic Planning Committee will explore the feasibility of an incentive program that will encourage BIS and ALS providers to participate in these ef- forts. If possible, the incentive pra gram should commence in January, 1998. 1988 Many strategic initiatives require sub- stantial lead time for analyses and pilot studies. Eazly planning and develop- ment will assure that full implementa- tion can comm�ce in years two, three, or four of the levy period when the ben- efits of the strategies will be most needed. The following describes the strategic initiatives and financing mecha- nicmc to be started in 1998. 1. During the new levy period, EMS pro- viders will explore addifiional ways to optimally utilize existing resou�es. ALS and BLS providers may need to collabo- rate with other health care entities. The EMS Division will continue dis- cussions with local healtti plans and providers on methods to educate consumers on cost-effective use of the Emergency Medical Services sys- tem. Collectively, EMS providers, health plans, and other health care providers will work to m�n�m;�p du- plication of services across the health care system through service delivery mechanisms that a assure patients receive care in the most appropriate setting by the most appropriate pro- viders. • A major strategic initiative during the next levy period is to utilizeALS resources as efficiently as possible. ' �� j �� 41 '�j { � monitor and reduce costs wherever pos- sible. To assist i» this effort, regional costsavingprograms should be initiated early in the levy period to maximize po- tential benefits. As a transitional advisory committee, the EMS Strategic Plan Steering Committee will work with the EMS Division to de- velop and implement the following cost saving programs: A regional joint purchasing program for medical and office supplies will be developed, allowing EMS provid- ers access to better purchasing dis- counts than might be available to in- dividual agencies. Planning and de- velopment will be started during 1997 for full implementation first quarter,1998. The feasibility of a new vehicle re- placement, salvage, and retrofit pro- gram will be studied during 1997. The goal of this program is to extend the useful life of paramedic vehicles to as much as five years by: — purchasing heavier chassis with longer useful lives; — replacing chassis periodically rather than entire vehicles; and/ or — recouping some of the cost through resells at the end of their useful lives. The EMS Division needs a mecha- nism to monitor strategic and finan cial performance throughout the next levy period. During 1997, the Division will enhance its monitoring database and work with �BLS and ALS providers to assure that data are collected and reported in a timely manner. The EMS Division will work with the interim EMS Advi- sory Committee to develop mea- sures for monitoring contract perfor- mance, utilization leveLs, funding re- quirements, and cost-savings. Participation in regional cost reduc- tion programs and performance monitoring processes is very unpor- tant to the success of the 1998 - 2003 Strategic Plan. The EMS Strategic Planning Committee will explore the feasibility of an incentive program that will encourage BIS and ALS providers to participate in these ef- forts. If possible, the incentive pro- gram should commence in January, 1998. 1998 Many strategic initiatives require sub- stantial lead time for analyses and pilot studies. Early planning and develop- ment will assure that full implementa- tion can commence in years two, three, or four of the levy period when the ben- efits of the strategies will be most needed. The following describes the strategic initiatives and financing mecha- nisms to be started in 1998. 1. During the new levy period, EMS pro- viders will explore additional ways to optimally utilize existing resou�rxs. ALS and BLS providers may need to collabo- rate with other health care entities. The EMS Division will continue dis- cussions with local health plans and providers on methods to educate consumers on cost-effective use of the Emergency Medical Services sys- tem. Collectively, EMS providers, health plans, and other health care plOVldeIS Wl'll wOI'k to minimi��+ du- plication of services across the health care system through service delivery --_ -- mechanisms that a assure patients receive care in the most appropriate setting by the most appropriate pro- viders. • A major strategic initiative during the next levy period is to utilizeALS resources as efficiently as possible. 41 � One way to accomplish this objec- tive is to explore the feasibility of revising the criteria based dispatch guidelines to: - more narrowly focus ALS re- sources on very serious and major life-threatening injuries and illnesses; - potentially redirect some BLS calls to more appropriate social and health services; and - expand the scope of BLS respon- sibilities. This requires continuing discussions with dispatch agencies about train- ing and possibly funding. This will aLso require initiation of discussions and possible collaboration with other social and health service pro- viders to assure that 9-1-1-callers are appropriately managed. It is anticipated that this initiative will involve a series of incremental changes that will occur over the course of the next levy period. De- finitive study and analysis of cost, quality, and value added issues will need to be completed before any changes can be implemented. The Medical Program Director will have oversight responsibilities of this work effort. In that capacity, he will work with his medical control physicians , pazamedic representa- tives, EMT's, and dispatchers to de- velop a process for planning, evalu- ating, implementing, and monitor- ing potential changes to the criteria based dispatch guidelines. During the first half of 1998, this group will develop the process and identify various types of cases as potential candidates for change. (Should tim- ing and resources permit, this part of the implementation process may commence in 1997.) ! Throughout the latter half of 1998 and during 1999, the MPD will over- see development and implementa- tion of a series of pilot studies to evaluate the medical risks and li- abilities of the proposed changes. The results of the studies will deter- mine whether or not the changes should be implemented county- wide. Management of growth in BLS and ALS calls is very important to the success of this strategic initiative. Prior to county-wide implementa- tion of new triage guidelines, the MPD and the EMS Division will as- sure that dispatchers and EMT's are adequately prepared to carry out any new responsibilities through additional training and education. The EMS Division will explore col- laborations with other social and health service entities to assure that the needs of EMS refenals can be appropriately met. If possible, a bro- chure outlining the availability of social and health services will be made available for BLS providers to leave with patients, directing them to non-EMS services for non-urgent needs. EMS providers have identified a need for more flexible transport des- tinations. Preliminary discussions with health plans and providers in- dicate that cooidination and collabo- ration on this topic could result in cost savings, enhanced quality, and greater continuity of care. Develop- ment and implementation is very complex and may require a two to three yeaz phase-in period. Major steps in the process include the fol- lowing: - The EMS Division will finalize its initial discussions with health plans and providers to establish a common understanding about an array of transport destina- ��; �� ; 42 ` J 0 tion options and to provide a set of policy guidelines for moving forward with this collaborative effort; The Medical Program Director will work with the medical con- trol physician workgroup, EMS providers, and health plan rep- resentatives to identify and evaluate those EMS cases which may be medically appmpriate for non-emergency room trans- port destinations; The EMS Division will identify health care facilities interested in accepting EMS transports and work with them to develop a program. This may involve a pilot project to test the efficacy and financial feasibility of the praject prior to implementation county-wide; The EMS Division, in concert with the MPD, EMS Trauma Council, and the EMS Advisory Committee, will revise and re- fine transport disposition and destination guidelines for uni- form implementation of this new program, assuring compli- ance and compatibility with other program plans; and The EMS Division will coordi- nate a public education cam- paign to increase awareness of this option. This effort could be integrated into other public edu- cation programs within the Health Depaztment or the Fire Service. Increased utilization of existing BLS and ALS resources may involve greater coordination with private ambulance transporters. The EMS Division and the EMS Advisory Committee will continue to evaluate private ambulance transports. � 2. The EMS Division is currently respon- sible for programs and services other than those defined as core regional func- tions. The Division will need to access additional sourres of revenue to fund its non-core activities and to avoid any dis- ruption of these sernices. The EMS Division will explore the feasibility of finding other funding sources or alternative service deliv- ery methods necessary to support - Emergency preparedness ser- vices for the Health Department and - CPR training for County employees - School CPR - Injury and illness prevention and education programs 3. A major objective of the 1998 - 2003 EMS Strategic Plan is to manage the rate of gmwth in ALS and BLS call volume. This is a long term initiative, requiring extensive public education and injury and iliness prevention programs in ad- dition to strategies designed to use ex- isting resources even more cost-effec- tively. EMS providers cannot achieve the desired results alone. Collaboration with other health care entities is needed. Consistent with plans currendy in progress, the EMS Division will con- tinue to work with the health depart- ment to integrate injury prev�tion and intervention programs into a uniform public health education program. The EMS Advisory Com- mittee will assist the Division in de- veloping the "message" to be pub- licized regarding the appropriate use of 911 for medical emergencies. This should be completed as eazly in the levy period as feasible. Refeaal of non-urgent 9-1-1 calls to more appropriate types of assistance may aLso help manage the rate of growth in demand. Dispatch screen- .�' � �� i • tion options and to provide a set of policy guidelines for moving forwazd with this collaborative effort; 0 The Medical Program Director will work with the medical con- trol physician workgroup, EMS providers, and health plan rep- resentatives to identify and evaluate those EMS cases which may be medically appropriate for non-emergency room trans- port destinations; The EMS Division will identify health care facilities interested in accepting EMS transports and work with them to develop a pmgram. This may involve a pilot pmject to test the efficacy and financial feasibility of the project prior to implementation county-wide; The EMS Division, in concert with the MPD, EMS Trauma Council, and the EMSAdvisory Committee, will revise and re- fine transport disposition and destination guidelines for uni- form implementation of this new prograzn, assuring compli- ance and compatibility with other program plans; and The EMS Division will coordi- nate a public education cam- paign to increase awareness of this option. This effort could be integrated into other public edu- cation programs within the Health Department or the Fire Service. Increased utilization of existing BLS and ALS resources may involve greater coordination with private aznbulance transporters. The EMS Division and the EMS Advisory Committee will continue to evaluate private ambulance transports. 2. The EMS Division is curnently respon- sible for programs and sernices other than those defined as core regional func- tions. The Division will need to access additional sounces of revenue to fund its non-core activities and to avoid any dis- ruption of these serr�ices. The EMS Division will explor� the feasibility of finding other funding sources or altemative service deliv- ery methods necessary to support - Emergency preparedness ser- vices for the Health Department and - CPR training for County employees - School CPR - Injury and illness prevention and education prograzns 3. A major objective of the 1998 - 2�3 EMS Strategic Plan is to manage the rate of growth in ALS and BLS cali volume. This is a long term initiative, requiring extensive public education and injury and illness p�evention programs in ad- dition to shategies designed to use ex- isting resources even more cost-effec- tively. EMS providers ca�aiot aci:ieve the desired results alone. Collaboration urith other health care enfities is aeedetl. Consistent with plans currendy in progress, the EMS Division will con- tinue to workwith the health depart- ment to integrate injury prevention and intervention prograa►s into a uniform public health education program. The EMS Advisory Com- mittee will assist the Division in de- veloping the "message" to be pub-. .._._:_ licized regarding the appropriate use of 911 for medical emergencies. This should be completed as eazly in the levy period as feasible.. Referral of non-urgent 9-1-1 calls to more appropriate types of assistance may aLso help manage the rate of growth in demand. Dispatch screen- C� .� �4 I ...^..-.- 43 � ing criteria and on-site referral cri- teria will be developed by the MPD to assure all 9-1-1 ca1Ls receive a level of assistance appropriate to their needs. In the future, this may not always include a BLS response. Health plans and other health care providers can assist in educating their patients on the proper use of 911 for medical emergencies. The EMS Division will continue its coor- dinating efforts with health plan rep- resentatives to assure that EMS objectives for universal access and public/community service are con- sistent with appropriate patient dis- position. 1999 The second yeaz of the 1998 - 2003 EMS Strategic Plan will be devoted to ongo- ing development of strategic initiatives launched in 1998 as well as initiation of two new strategic efforts. Decisions about implementation funding will be decided in concert with the EMS Advi- sory Committee. While the first year fo- cuses on establishing the foundation for collaborations and building of extemal relationships, the second yeaz will focus on internal program improvements. 1. A major new initiative for the next levy period is to expand existing perfor- mance standards and incorporate those standards into EMS levy fund contracts for BLS providers. The Medical Program Director will oversee development of new BLS standards. This may include work- ing with the EMSAdvisory Commit- tee as well as ad-hoc subcommittees to provide substantive assistance as needed. There are three basic areas of exploration and development. • Changes in service delivery methods and mechanisms posed within this � strategic plan may require that BLS providers monitor additional perf or- mance indicators to measure how well the EMS system in total is meet- ing its new obligations. Previous to this Strategic Plan, BLS performance standards focused on response times, out-of-service times, call vol- ume within the designated service area, and back-up call volume in neighboring jurisdictions. Addi- tional detailed data may be needed to more efficiently monitor BLS ser- vices. With proposed strategic changes, it will be necessary to collect data on quality, outcome, patient satisfaction and other key elements• This infor- mation will provide input for ongo- ing system-wide unprovement over the course of the next six years. In addition, BLS providers will need to collect and report data in support of contract compliance monitoring. Flexible transport destinations will require new BLS destination trans- port guidelines. The MPD will work with representatives of BIS provid- ers, private transporters, and health plan representatives to develop a new set of transport criteria and standazds. There is a need to establish BLS stan- dards that promote medically appro- priate, cost-effective and efficient EMS services. In connection with contract performance criteria, the EMS Division and the Medical Pro- gram Director will oversee develop- ment and implementation of incen- tives that promote accountability and stewardship of EMS levy funds expended by BLS contractors. 'This may be a lengthy process of col- laboration across BLS providers. However, there is time to pursue this area of exploration and development designed to unprove service deliv- ' �) . � � �� 44 � ery across jurisdictional boundaries. Success will assure that a minimum level of EMS service will be estab- lished throughout the County and uniformly implemented. 2. The 1998 - 2003 Shategic Plan in- cludes only one new ALS unit to seme Countygrowth and expansion. This urill be a significant operational challenge to the EMS System and new semice deliv- ery methods may be needed. Data collection and analysis will be very important to monitor utiliza- tion of ALS services throughout the County. It may be necessary to en- hance technical support services within the EMS Division for ex- panded planning and management of the system. Current information systems are designed to monitor ALS unit locations, response times, out-of-service times, simultaneous responses, and out-of-area calls. This data is important, but will need to be expanded to include analysis of additional variables that support new service delivery options. Iden- tification of additional data elements and revision to data collection meth- ods needs to occur no later than 1999. New service delivery options in- clude the possibility of varying re- sponse time standazds for someALS calls, alternative ALS scheduling mechanisms, or intervention pro- grams for the chronically ill and re- cent hospital discharges. Data will be needed from EMS as well as other health care providers to assess the cost-effectiveness of service delivery options and to evaluate the impact on quality and patient outcomes. Data will need to be collected before any feasibility assessment can be completed. Potential operational changes within the ALS system will require careful evaluation and assessment though � data analysis and pilot projects Dur- ing 1999 and 2000, the EMS Division needs to be prepared to design and carry-out a number of pilot studies to test the operational and patient care implications of newAlS service delivery options. 3. During 1999, the EMS Division will initiate plans to develop and implement the practice of call prioritization through dispatch. This will build upon program initiatives implemented to date, assuring that dispatch semices have the resourres necessary to support new and revised EMS guidelines and ser- vice delivery methods. 2000 1. During 2000, the EMS Division will explore the feasibility of securing out- side funding for new programs. The 1998 - 2003 EMS Strategic Plan includes two new programs that will enhance the EMS system. Funding for these programs is not included in the financial plan, requiring the EMS Division to secure funding from external sources. By 2000, the EMS Division should be positioned to explore funding opporiunities for the new programs. If time permits, this effort could occur in earlier years. During 2000, the EMS Division will work with the University of Wash- ington to secure new grant funding to expand the cazdiac azrest surveil- lance program to all EMS calls. This would provide a database for EMS research unpazalleled across the na- tion, allowing outcomes research and analysis of EMS service deliv- ery mechanisms. � Collaborations with local health plans and providers provides an op- portunity to share and integrate ' �) �� 45 � � � - ery across jurisdictional boundaries- Success will assure that a mirumum level of EMS service will be estab- lished throughout the County and unifortnly implemented. 2. The 1998 — 2003 Strategic Plan in- cludes only one new ALS unit to serr�e Countygrowth and expansion. T7iis will be a signi�icant operational challenge to the EMS System and new semice deliv- ery methods may be needed. Data collection and analysis will be very important to monitor utiliza- tion of ALS services throughout the County. It may be necessary to en- hance technical support services within the EMS Division for ex- panded planning and management of the system. Cuaent information systems are designed to monitor ALS unit locations, response times, out-of-service times, simultaneous responses, and out-of-area calls. This data is important, but will need to be expanded to include analysis of additional variables that support new service delivery options. Id�- tificatian of additional data elements and revision to data collection meth- ods needs to occur no later than 1999. New service delivery options in- clude the possibility of varying re- sponse time standards for some AIS ca1Ls, alternative ALS scheduling mechanisms, or intervention pro- grams for the chronically ill and re- cent hospital discharges. Data will be needed from EMS as well as other health care providers to assess the cost-effectiveness of servi�e delivery options and to evaluate the impact on quality and patient outcomes. Data will need to be collected before any feasibility assessment can be completed. data analysis and pilot projects Dur- ing 1999 and 2000, the EMS I?ivision needs to be prepared to design and carry-out a number of pilot studies to test the operational and patient care implications of newALS service delivery options. 3. During 1999, the EMS Division will initiate plans to develop and implement. the practice of call prioritization through dispatch. This will build upon program initiatives implemented to date, assuring that dispatch services have the resourices necessary to suppo�t new and revised EMS guidelines and ser- vice delivery methods. 2000 1. During 2000, the EMS Division will explore the feasibility of securing out- side funding for nezv programs• The 1998 — 2003 EMS Strategic Plan includes two new programs that will enhance the EMS system. Funding for these prograzns is not included in the financial plan, requirinS the EMS Division to secure funding from external sources. By 2000, the EMS Division should be positioned to explore funding upportunities for the new programs. If time permits, this effort could occur in earlier years. During 2000, the EMS Division will work with the University of Wash- ington to secure new grant funding to expand the cazdiac arrest surveil- lance program to all EMS calls. This. .: _�_ would provide a database for EMS research unparalleled across the na- tion, allowing outcomes reseazch and analysis of EMS service deliv- ery mechanisms. Potential operational changes within . Collaborations with local health the ALS system will require careful pians and providers provides an op- evaluation and assessment though portunity to share and integrate "�I G� �, 45