Trinity County Life Support Annual Report 2019

Trinity County Life Support (TCLS) has served the communities of Weaverville, Douglas City, Lewiston, Junction City, Downriver, Big Bar, Hayfork, Hyampom, Post Mountain, and Wildwood for 27 years.

The non-profit was formed in 1993 when for-profit and hospital-based ambulance services failed.   TCLS service area, 85% of Trinity County, is approximately 2,100 square miles.  We are bordered in the South by Southern Trinity Area Rescue, serving Mad River and Zenia-Kettenpom, and in the West by Hoopa Ambulance, serving Hawkins Bar, Salyer and Burnt Ranch. 

HIGHLIGHTS OF 2019

The biggest accomplishment of 2019 is remaining open and functional with two 24/7 ambulances.  This is our all-consuming goal, we’re still here. 

In this time of downturn, we have been able to

• Protect patient care staffing from reduction
• Respond, treat patients, make decisions for best outcomes
• Provide inter-facility transfers with critical care scopes of practice
• Transport patients with 100% safety
• Add TXA and push dose Epinephrine to our Paramedic local scope of practice
• Add Benadryl and Aspirin to our EMT scope of practice
• Paramedics administered TXA multiple times with good benefit in internal and external bleeding
• Paramedics administered push dose Epinephrine for critically ill or injured patients
• EMTs stepped up when paramedic staffing was not possible, staffing BLS 303 in Hayfork
• Together with our volunteer fire personnel we successfully treated patients who may otherwise not be here, and worked hard many times over to help patients in need

LOWLIGHTS of 2019

The reserves built by the service over many years are dwindling.  We have one last year 2020, to see us through the General Election, and then deficit budget/spending must stop. 

We are struggling and losing capabilities in the areas of training and backup ambulance response.  We were not able to put on our annual EMS EXPO and some of the other additional training events that have been a staple here.  Training is one of the things that sets TCLS apart from other small services.  

• Primary Election — Failure of Measures D and E for stable ambulance service
• Continued low recruitment of paramedics due to shift structure and lack of 24-hour pay
• Hayfork 303 staffed basic life support for 33 days, 9% of the year
• Programs and training impacted by unfunded management position
• Unable to offer annual EMS EXPO for our staff and our volunteer fire departments
• Unable to offer annual EVOC Course (Emergency Vehicle Operations Course)
• Unable to provide consistent backup ambulance response due to staffing

RESPONSE STATISTICS

Inter-Facility Transport (IFT) – Medically necessary, physician ordered transport, generally from Trinity Hospital to a hospital with higher-level care or specialty care e.g., cardiac or intensive care.

IFT to LZ – Transport to Redding Municipal Airport for transfer to fixed wing airplane to out of the area hospital for specialty care.

Air ambulances were utilized for 11% of patients transported. 

ALS – Advanced Life Support – Team of one paramedic/one EMT

BLS – Basic Life Support – Team of two EMTs

LZ – Landing zone

Consistently over the years statistics show that 90% of patients are local citizens. 

STAFFING

TCLS staffing is typically four full-time EMTs, four full-time paramedics, 1 full-time office position, 1 full-time management position.  A roster of ten supplemental EMTs and paramedics is maintained to fill the schedule and cover sick and vacation time. 

Desired staffing is an EMT and paramedic on each ambulance, in Weaverville and Hayfork.  This is not quite enough to serve the call volume.  The crews need backup and this is dependent on the manager and off-duty personnel responding, something far less than ideal with the current crew shift structure and very real lack of needed dedicated management hours. 

This year the ambulance crews worked a total of 29,330 hours with 100% safely in vehicle operations.  Injuries, frequently at zero, were up this year with a needlestick, a blood exposure, and two stress related injuries.   

Crews in Weaverville sometimes are up and down Buckhorn three and four times a day or night and more if that’s what the patient’s condition warrants.  Some direct from scene, some transferred out of our local hospital for higher level of care.   We have a very large area to cover.  More backup is needed. 

When TCLS is unable to staff a third ambulance on demand, this is hard on the first-out crew, and puts the team at risk.   It also impacts the patient, the hospital, and our volunteer fire departments.  They must wait on the scene, caring for the patient longer than normal, away from family or jobs. 

In 2019, 37 patients in Hayfork received initial BLS ambulance response.  This means two emergency medical technicians (EMTs) responded on the ambulance, rather than our standard of one EMT and one paramedic. 

Our BLS staff is strong and we value their skills.  The difference in scope of practice between EMT and paramedic is significant with the paramedic having advanced skills and medications that make a life-saving difference.  Early advanced life support is very important in a rural and remote area. 

Our challenge in paramedic recruitment and retention is long-term.  Paramedics gain training and experience here.  With that experience they can be hired elsewhere for a better wage and shift.  Trinity County is a difficult place to work in the very best of ways.  It is challenging and rewarding.  There is little backup.  The responder must be well-trained and competent.  We have you in our care for a long time. 

To retain advanced life support staffing we must address

• Lack of competitive pay
• Lack of 24-hour pay for a 24-hour shift worked
• Shift structure that is stressful for families and fatiguing (three consecutive 24-hour shifts)

AMBULANCES AND EQUIPMENT

• Weaverville 301 – 2016 AWD Sprinter Van
• Hayfork 303 – 2013 Chevy E3500
• Weaverville 302 – 2008 Ford E350
• Weaverville 308 – 2002 Ford E350 with new transmission/engine in 2008

The Sprinter van purchased in 2017 is $30,000 less in purchase price, fuel efficient, and adds many safety upgrades including all wheel drive, over the Ford E350 Diesels we are retiring.  TCLS has secured a grant from USDA Rural Development for 75% of the cost for a 2019 AWD Sprinter Van for Hayfork.  We are in discussion with McConnell Foundation for additional support for this purchase, which will occur in 2020.

All four ambulances are stocked with full advanced life support capabilities.  TCLS is grant-seeking to replace four (4) cardiac monitors that were purchased in 2002.  This project will cost $104,000 for refurbished equipment and $130,000 for new.  Existing equipment, though well-maintained, will become obsolete after December 2022.  Cash reserves, relied upon currently to protect ambulance staffing, are inadequate for stability and grant matches.    

PUBLIC SAFETY TRAINING FACILITY

TCLS has a strong history of high-quality training and outreach to the volunteer fire departments.  The relationships, the interaction, the trust built by this joint training cannot be lost.  It is being impacted by lack of staff and funding.  This training makes Trinity County unique.  The resulting teamwork helps makes Trinity County emergency response a cut above. 

Our training center serves Trinity Hospital and Trinity County Fire Departments with American Heart Association BLS (Healthcare Provider CPR).

Community level trainings are provided based on need, many classes are for non-healthcare workplace requirements and schools, coaches. 

Public Safety First Aid is the course required by Title 22 and approved by the California Emergency Medical Services Authority.  This is the base requirement for volunteer fire and law enforcement personnel. 

We teach Emergency Medical Responder, an excellent scope of practice for rural responders.

We partnered with Weaverville Fire Protection District in 2016 to create an Emergency Medical Technician (EMT) course locally.  Prior to that, this training was provided by Shasta College.  The Shasta College minimum enrollment requirement of 25 students consistently resulted in course cancellation due to low enrollment and ultimately resulted in a lack of EMTs for hire and response.     

EMT training is valuable and life-saving.  Local EMTs are needed.  This entry-level introduction to the emergency medical services can result in a life-long passion for helping people.  EMT training can lead to higher career paths in healthcare and provide the student with a ground level view of the whole system.  EMT training is critical to the TCLS mission of patient care, EMTs are the foundation of the service and they are the next generation of paramedics. 

TCLS minimum enrollment of 10 was not met in 2019.  We’ve kept our tuition as reasonable as possible and are grant-seeking for tuition matches for volunteer fire department personnel and high school students so that we can fill the classes and provide vocational education.     Mountain Community Healthcare Foundation has a program of funding to help with the expense of EMT training. 

REVENUE AND EXPENSE

Accounting is done on an accrual basis.  Figures are from unaudited actuals. 

Patient income was outsourced to a billing company in 2011 and has been steadily increasing.

Memberships – 11% of the service area are members, slightly above average for this type of program.  The membership program is at most times a break-even program for TCLS, beneficial to the member, beneficial to cash flow.  In 2019 membership revenue of $66,815 with $50,025 in balance bill write-offs. 

Community outreach revenue is public safety course fees and donations. 

Fire camp contracts provide an opportunity for staff to earn extra income and helps TCLS with cash flow and reserves.  To commit to a fire camp contract, our agency must be at a healthy staffing level to cover a third ambulance 24/7 for the duration.  Reserves also must be adequate for payroll up front, reimbursement from the fire to follow. 

Deficit spending began in 2014.  The Board of Directors, always adamant regarding a balanced budget, went out on this limb to protect staffing levels.  Efficiencies, cuts, diligence in progress long term.

At this time TCLS is relying on reserves that were painstakingly built over many years to protect services, sometimes able to offset with fire camp revenue.  2020 projections see a precipitous drop in cash reserves and the largest budget deficit ever.  Key reasons are rising costs and reimbursements not covering costs, not keeping pace with rising costs. 

Ambulance purchases occurred in 2017 and 2020.  Election expense is a large projection in 2020. 

Small rural services across the United States are struggling financially, reducing services, some are shutting down.  TCLS has been holding the line on reducing patient services.  Two ambulances fully staffed is a minimum to safely serve this large area. 

The factors most detrimental to rural services

• Medicare reimbursement is less than the cost of providing service
• Medi-Cal reimbursement is less than the cost of providing service
• Rural areas commonly have a high percentage of Medicare and Medi-Cal
• Rural areas do not have the high call volume of urban areas to help offset this

If a business sells its goods or services at less than the cost of providing it, how long can it operate? 

TCLS has made it work for a long time, 27 years now.  Of patients served in 2019 –

• 49% Medicare
• 28% Medi-Cal
• 23% All Others — cannot offset losses

TCLS has been holding off cuts to patient care services with reserves and cannot offset the revenue shortfalls of Medicare and Medi-Cal indefinitely.  Services are at real risk.  Like any business, TCLS will go under at current income and expense.   

The law requires healthcare facilities to accept the payments allowed by Medicare and Medi-Cal as payment in full.  The exception to this, your annual Medicare deductibles, the patient’s responsibility.  (These are the write-offs that Membership provides, plus insurance deductibles and maximums.)

The government has long underfunded healthcare facilities with Medicare and Medi-Cal. 

A new program GEMT QAF, taxes ambulance providers on all transport revenues, leveraging a federal match, returned in the form of increased Medi-Cal reimbursement.  This program results in payments of between $5,000-$6,000 per quarter to the State.  The State keeps some discretionary funds and increases the Medi-Cal reimbursement emergency transport base rate from $118 to $226.   

The current reimbursement system does not pay unless a patient is transported, even when non-transport is the most beneficial and sensible for the patient and system.   Non-transports are either a response, assessment, possible care and release, or a patient refusing transport against medical advice.

Non-transport for 2019 was 27% of call volume.  We do not “transport everyone” for the potential revenue.  Unnecessary transport affects hospitals adversely.  Transports are not paid if they do not meet criteria for medical necessity.     

This is slowly changing as ambulance services are becoming recognized by insurance companies as healthcare providers rather than ride-givers.  The cost benefit of care and non-transport has been recognized by the insurance sector.  Government programs are projected to slowly follow this course and we are tracking this. 

TCLS reserves, built for stability in hard times, built to address facility and equipment needs, are serving to keep two 24/7 ambulances staffed.  We are operating without a safety net.   

Projections for the year 2020 show an ending cash balance of just under $200,000, 40% of what it should be.  Reserves have not been this low since 2011.  Medicare often freezes payments.  When a Medicare Revalidation occurs, we expect to be without Medicare payment for up to six months. 

At the close of 2020 TCLS must cease deficit operations and make reductions that will change our service, not for the better.  Protecting a level of high quality and proficiency is crucial in the rural areas where you are far from care. 

We continue to look at new ways to make this go.  Alternative medical transport (non-emergency), community paramedic, training facility expansion.  All of this requires a level of financial health and stable staffing, which TCLS is losing. 

Without some stable base funding to help offset the shortfalls of Medi-Cal and Medicare, we are very limited.   We have one more year to operate at a deficit, protect two 24/7 staffed ambulances, and get a solution in place.  After 2020, without a solution, we face reductions that will impact ambulance staffing, patient care, and public safety.   

CONCLUSION

In March of 2020 we submitted an addendum to our initial LAFCO (Local Area Formation Commission) application.  This application went through the required public meetings, receiving the approval of LAFCO and the Trinity County Board of Supervisors, for November General Election.

The new measures propose

• Formation of a special district for ambulance services – this provides access to government reimbursement programs for Medi-Cal shortfalls that we cannot access as a non-profit
• Request for annual $45 parcel tax assessment on residential and commercial development – this provides approximately $258,000 in stable base funding for the ambulance operation
• There is no tax for vacant parcels or parcels with minor improvements

This request is pared down to essentials.  There are no improvements.  This request will keep two 24/7 ambulances staffed for 911 emergencies in Weaverville and Hayfork.

Voters will choose — Do we save Trinity County Life Support or NOT? 

The consequences of NOT are reduced emergency services and capabilities.  Critical care, so important to good outcomes in this rural area, may be lost. 

When you call 911, you expect someone to come quickly, you expect competence, reliability and safety.  TCLS is that safety net.  90% of TCLS patients are local people, our friends and neighbors.

$45 per year for secured ambulance service.  TCLS cannot promise yet that we would be able to put this funding aside in the future, as Mountain Communities Healthcare District has been able to do. 

The Board of Directors, when making application revision to LAFCO, did not feel they could safely put a 5-year sunset of this tax.  The funds that have stabilized our hospital (healthcare reform) will greatly help.  There are many programs for hospitals and clinics that just do not exist for ambulance services. 

The long-term goal is self-sufficiency and quality service.  We must see the emergency services stable into the future. 

A stable service can give back much to the community. 

Your contributions go directly to the preservation and betterment of emergency medical care; to an agency that is a diligent steward of its resources, no waste. 

If you can value stable EMS at $45 per year, it is important to your safety and those around you.