1. EMS Workforce in the Hospital
National Rural EMS Conference -Fargo, ND
April 2017
Kenneth Reed, MS, NRP, CCP-C, CP-C
Director of EMS & Disaster Services
Heart of America Medical Center – Rugby EMS

2. Gary Wingrove Cannot Be With Us Due To A Death In His Family

3. A Little Bit About Me Been in EMS since 1973
Paramedic School in 1975
Worked in both ground and air medical transport programs.
EMS Leadership & Education for over 35 years
Live & Work in Rugby, ND
EMS Director – Rugby EMS
Certified Community & Critical Care Paramedic
ND EMS Advisory Board

4. Federal FLEX Program and EMS
Short history of the program and relationship to EMS
From the BBA of 1997
Origin was for a 50/50 split of funding for Rural Hospitals & EMS Services
In practice, Hospitals have received a larger percentage of the funding
Original program had two primary funding priorities
Cost based reimbursement for CAHs
Medicare Cost Reporting – 101% of costs of operation
In exchange for “curtailed” services and bed capacity
Cost based reimbursement for ambulance services
CAH must own and operate
No other ambulance service in 35 miles of travel on improved roads
Doesn’t count “gravel” or minimally maintained county highways

5. The ”Circle” Regulation
These represent the situations in which a hospital-operated ambulance service would be eligible for cost-based reimbursement

6. These represent the situations in which a hospital-operated ambulance service would not be eligible for cost-based reimbursement

7. Cost-Based Reimbursement of Ambulance
Service must be owned and operated by the Critical Access Hospital (CAH)
Medicare pays initially based on fee schedule
CAH submits a “Cost Report” annually
Medicare pays a supplemental payment based on validated cost report
Only covers the percentage of Medicare patients served

8. There Are Other Potential Cost Recovery Options
EMTs and paramedics can work in the CAH (or rural health clinic) as allied health staff
Their supervision and delegation of practice is physician directed
As part of the CAH (or rural health clinic) staff, their costs are part of the cost report when working in the facility
When they do ambulance runs, they “clock out” of the CAH and “clock on” to the ambulance fee schedule
They may be employed by the CAH or contracted to the CAH by the EMS agency

9. BUT WAIT!, YOU HAVE TO BE A DOCTOR OR NURSE TO DO PATIENT CARE IN A CRITICAL ACCESS HOSPITAL, RIGHT?

10. CAH Survey Requirements
Not only CAN EMS personnel work in the CAH, the CAH is REQUIRED to assess how many they need
CMS State surveyor’s manual:
“The CAH must determine the categories and numbers of MD/DOs, specialists, RNs, EMTs, and emergency department support staff the CAH needed to met [sic] its anticipated emergency needs.
The medical staff must establish criteria, in accordance with State law and regulations and acceptable standards of practice delineating the qualifications required for each category of emergency services staff (e.g., emergency physicians, specialist MD/DO, RNs, EMTs, mid-level practitioners, etc.).”
Guidance/Guidance/Manuals/Downloads/som107ap_w_cah.pdf

11. EMTALA is not a barrier
It is a common misconception that EMTALA “requires an assessment by a physician or nurse” for patients that come to the hospital.
EMTALA does not require the exam be conducted by a physician or nurse. In fact, the words “physicians and nurses” together or separate do not even appear in screening exam personnel requirement paragraph of the regulation.

12. EMTALA is not a barrier
EMTALA requires a screening exam by a qualified person. Specifically, EMTLA requires:
§489.24   Special responsibilities of Medicare hospitals in emergency cases.
…… Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations…… (Emphasis added.)

13. EMTALA is not a barrier
Further, CMS directs the state agencies that investigate EMTALA complaints in any hospital this way:
“Once an individual has presented to the hospital seeking emergency care, the determination of whether an EMC exists is made by the examining physician(s) or other qualified medical personnel of the hospital.” (Emphasis added.)

15. North Dakota Critical Access Hospitals & EMS
There are 36 Critical Access Hospitals in ND
118 Licensed Ground Ambulance Services
Only 8 CAHs own or operate EMS services
Rugby EMS
ALS Licensed Ambulance Service serving Pierce County
Staffs 2 ambulances 24/7
Averages 400 – 450 transports annually / 600 – 700 runs per year
Active Community Paramedic program
Transitional & Chronic Care programs for Rural ACO
Hospice Back-up
Home lab draws, Wound care and rural clinic referrals
Co-Staffing of ER with ER
One of two paramedics scheduled daily are on nursing budget
Community Education

16. Poster State: Nebraska
Nebraska has a rich history of hospitals employing EMS practitioners and operating ambulance services
SEE HANDOUT

17. Minnesota CAH In-Hospital examples
…paramedics help with room assignments/triage, and assist with IVs, suturing, bandaging and casting, as well as provide cardiac arrest response and manage violent patients…
…EMTs are not on ambulance call while working in the hospital. They assist with triage, take vital signs, splint, set up trays, apply dressings, restrain patients when necessary, provide patient education, start IVs, perform 12-lead EKGs and insert Foley catheters…
…hires paramedics and trains them to be Respiratory Therapists. The paramedics perform in-house RT functions between ambulance runs…

18. Minnesota CAH In-Hospital examples
…trained many of its maintenance staff to become EMTs and eventually paramedics… respond to cardiac arrests, trauma codes, helicopter assists, and mental health assists…called in to assist with triage, vital signs, transporting, helping in X-Ray…
…perform initial triage, patient assessments, vital signs, give ACLS medications, assist with casting, breathing treatments, 12-lead EKGs and intubation. When needed, they will also assist with inpatient care…
…perform phlebotomy, monitoring patients during in-house transport, splinting and casting, wound care, suture prep…paramedics staff the telemetry monitoring facility in the hospital…

19. Questions, comments, discussion
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