A Critical Update
In this issue of New Jersey Municipalities we are exploring the issue of Emergency Medical Services (EMS) from a variety of perspectives. This article will review pending legislation that has been written based on studies and quality levels that the New Jersey Department of Health and Senior Services would like to see implemented. To further understand the topic we have asked six leading players in the EMS field to write separate articles that tell of their successes, challenges and views on the future of EMS in New Jersey.
By Chuck Chiarelllo, Mayor, Buena Vista and
League of Municipalities Executive Board Member
& Francis Pagurek, EMS Chief/Emergency Management
Coordinator, Mount Laurel Township
The views on EMS are many and varied. In putting together the EMS study some 32 different agencies (EMS Stakeholders) came to the table to have input in this process through the New Jersey EMS Council Ad Hoc Committee. From hospitals to the fire service, from volunteer ambulance to paid ambulance, the players were all at the table.
The Challenges—Goals vs. Reality Having the “best quality of EMS” no matter where in New Jersey you live or work is a goal set by the New Jersey Department of Health and Senior Services. The challenge is how to make that work within the budget structure we face in New Jersey.
While municipalities would also want the “best quality of EMS” available there is a realization that there are budget parameters to meet. The level of service that could potentially be achieved by the discussion that follows does have a financial impact that comes with it.
The Process for Change “The New Jersey Emergency Medical Services (EMS) System must change to continue effective delivery of prehospital care. The system’s financial structure, decline in volunteer membership, lack of comprehensive legislation, and weakened Advanced Life Support (ALS) system is in near crisis.”
The above is an excerpt from the first paragraph of the Introduction to the Tridata NJ EMS System Review, a report put together to evaluate EMS in New Jersey. We hope it grabbed your attention as it did ours. The EMS Community could probably write several books on how and why our state’s EMS System is in “near crisis,” but for this article we will focus on what the state has been doing to prevent a “crisis.”
In 2006, the New Jersey State Legislature mandated that a study be conducted to review the current EMS System and to determine immediate and future needs. Tridata, an internationally recognized emergency services consulting firm was selected to conduct this study by the New Jersey Department of Health and Senior Services (NJDHSS). In early 2007, Tridata began to collect information for
the study by conducting interviews with key EMS leaders, 13 focus groups or organizational and provider constituents, interviews with New Jersey Office of Emergency Medical Services officials and the triangulation (analysis) of data. Additionally, areas evaluated included; the structure of the state’s EMS System was compared to five other states, a review of the state’s current EMS Legislation, executive orders and regulations that govern EMS in New Jersey and the National Highway Traffic Safety Association’s “EMS Agenda for the Future.” In September of 2007, the study provided 55 recommendations. This study can be found at www.state.nj.us/health/ems.
In January of 2008, NJDHSS Assistant Commissioner of Health Dave Gruber charged the New Jersey Emergency Medical Services Council (NJ EMS Council) with the task of redesigning the state’s EMS System. The NJDHSS would not be the lead agency in the redesign but would provide support and empower the Ad Hoc Committee to perform this task. The Ad Hoc EMS System Redesign Committee requires the new system to be:
- a two-tiered system (Basic Life Support and Advanced Life Support)
- have a municipal mandate for EMS Services
- metric-driven with goals and a measurable outcome
- cable to use technology in its delivery and documentation systems
- sustainable and survivable
- diverse and flexible and must include both volunteer and commercial providers
- the new EMS System Design must facilitate its implementation
- recruitment and retention for EMS volunteer and Career services must be a priority
- all facets of the EMS System must be represented on the Ad Hoc Committee
- the process should not be secretive
- the plan must be ready to present to the legislators for implementation by November of 2008.
First, the NJ EMS Council Ad Hoc System Redesign Committee (Ad Hoc Committee) reviewed all 55 recommendations in the EMS Study and through consensus of the group accepted, rejected, or accepted with amendment, each of the study recommendations prior to the end of February 2008.
As the Ad Hoc Committee moved forward they identified other EMS System Stakeholders that were not represented on the NJ EMS Council to participate in the process. Representation from the New Jersey State League of Municipalities was one of the seats added to complete the 32 different EMS System Stakeholders that composed this new Ad Hoc Committee. Each seat on the Ad Hoc Committee had a delegate and an alternate.
Both authors of this article served on the Ad Hoc Committee. Mayor Chuck Chiarello was selected to represent municipal government on the Ad Hoc Committee along with an alternate member Francis Pagurek, EMS Chief/ Emergency Management Coordinator for Mount Laurel Township.
Moving forward, the Ad Hoc Committee met about twice a month through September 2008. Many subcommittees worked on specific topics in between regular committee meetings.
During the early part of this process it was quickly determined that this committee could not redesign New Jersey’s EMS System in the time allotted. The direction quickly changed to focusing on developing new EMS Legislation that would enable the EMS System to change as needed from the “grass roots” level and through the regulatory process.
On October 24, 2008 the revised EMS Council Version of the proposed EMS Legislation was completed with an EMS System Overview and an
EMS White Paper. The goal of having a completed product for the state Legislature prior to November 2008 was achieved.
EMS Legislation Listed below are seven points that explain what action the Commissioner of the New Jersey Department of Health and Senior
Services would take if this legislation was adopted. In the italicized writing after numbers 1 through 7, we have taken some editorial liberty to tell municipal officials what impact,
if any, these changes will mean to your community.
- Within two years of the adoption of this legislation, all municipalities shall assure or arrange for the provision of Basic Life Support (BLS) prehospital care in response to 9-1-1 calls by people within its boundaries, including continuation of coverage when the primary service is unavailable.
Most municipalities in New Jersey already provide or have volunteer organizations that provide BLS service, but presently, they are not required to provide these services.
The Commissioner, in consultation with the Emergency Medical Care Advisory Board (EMCAB), shall establish minimum standards for training, response times, equipment, and the quality of such services.
This language may impact the costs of providing EMS in municipalities and have a great impact on volunteers including the requirement of two EMTs on a volunteer ambulance.
- The State of New Jersey shall assure or arrange for the provision of Advanced Life Support (ALS) prehospital care in response to 9-1-1 calls within the state. The Commissioner, in consultation with the Emergency Medical Care Advisory Board, shall establish minimum standards for training, response times, equipment, and the quality of such services.
Not a direct municipal government impact, but may increase costs to the hospital- based ALS providers. May negatively impact the negotiated Medicare amount paid to a BLS provider in the reverse billing agreement. Also may improve ALS service delivery.
- The Commissioner shall establish through regulations minimum standards for credentialing any clinician or agency before such providers shall be permitted to respond to 9-1-1 medical calls in New Jersey.
This might have a financial impact if the national scope of the EMS Practice Model is adopted. First responder police and fire personnel will be required to meet state training standards to be credentialed as First Responders.
- The Commissioner shall institute objective standards to approve EMS dispatch agencies, and the standards must be designed to establish EMS call processing times (consistent with or more restrictive than the standards set forth in N.J.A.C. 17:24-23), appropriate triage of resources to respond to emergency calls, and a communications quality improvement process. Any provider entity shall be permitted to contract with any such approved entity. Any agency licensed or credentialed to provide 9-1-1 response in New Jersey shall maintain a written agreement with a dispatch agency approved by the Commissioner.
This may have a financial impact on municipalities and counties that
provide EMS Dispatching Services. Some towns may have to pay to
contract for dispatch services with a state approved Dispatch Center.
- The Commissioner, shall deliver annually a report to the legislature identifying the funding needed for the next fiscal year to adequately fund the needed infrastructure and research to encourage the continued improvement of quality prehospital care. This report shall be presented prior to the development of the annual budget.
This may result in unknown cost increases in the future or it may reduce the cost of local EMS service through direct and indirect local subsidies provided from state and federal funding.
- There shall be established in
the New Jersey Office of Emergency
Medical Services division of the New Jersey Department of Health and Senior Services the position of EMS Medical Director. The minimum requirements for this position shall be those established by N.J.A.C. 8:43G-12.3 for physicians practicing in the emergency department of a licensed New Jersey hospital.
No direct municipal impact, but will improve the quality of patient care throughout the state.
- In calculating funding from existing allocations under NJSA 26:2K-36.1 and NJSA 52:17C-19 shall not be redirected after the annual appropriations for those programs. Instead, at least 75 percent of the total allocation shall be reserved for the operation and support of the EMS system in New Jersey, including continuing the current appropriations under those laws.
Keeping a stable funding source is critical—one that is not subject to budget shifting.
The Legislative Process The New Jersey State Department of Health and Senior Services has sent the proposed draft EMS legislation to the Office of Legislative Services (OLS) for review prior to it being introduced as a bill.
Assemblyman Herb Conaway and Senator Joe Vitale each chair the Health Care Committee in their respective branches of the Legislature. They will likely introduce draft legislation in 2009 after holding public hearings on the Proposed Draft EMS System Legislation. We are confident that the Ad Hoc Committee’s Draft Legislation will be modified before being introduced. It is their stated goal to have the new Revised EMS Legislation voted on and signed into law prior to the end of 2009.
It is important as an elected or municipal official that you let your voice be heard with any concerns that you may have regarding this legislation and the impact it will have on your community.
The good news is that there are many service options on the table in providing quality EMS to our citizens. The articles that follow explore those options and address the pros and cons involved in each area.
Chuck Chiarello is Mayor of Buena Vista Township in Atlantic County and a member of the League’s Executive Board. He is an 18 year elected official and a former volunteer firefighter. Mayor Chiarello currently Chairs the League’s Municipal Emergency Management Preparedness Task Force.
Francis Pagurek is EMS Chief/ Emergency Management Coordinator in Mount Laurel Township and a paramedic with Virtua Health Systems in Burlington County. Chief Pagurek has been involved in EMS for 32 years.
This article was originally published in New Jersey Municipalities magazine. Vol. 86, No. 5, May 2009