NOVEMBER 2019

Issue Brief Left Behind in California: Comparing Community Paramedicine Policies Across States

Introduction Community paramedicine is a growing health care responding to 911 calls and transporting people to an model in which emergency medical professionals such as emergency department (ED). Some MIH services are paramedics and emergency medical technicians (EMTs) provided by paramedics, and some are provided by work beyond their traditional emergency care roles and other types of health professionals, such as nurse prac- provide nonemergency care. This model is based on titioners and registered nurses. local need and seeks to reduce unnecessary emergency department (ED) use and to connect underserved popu- CP usually refers to MIH services provided by para- lations with health care resources. Services are integrated medics that are beyond traditional EMS services. In into local or regional health care systems and overseen some cases, CP only connotes services provided by by emergency and primary care physicians. Examples of paramedics outside of response to 911 calls, such as services include furnishing posthospital follow-up care, providing home visits to people recently discharged providing health education programs, giving immuniza- from a hospital or providing case management services tions, and referring or transporting 911 callers to more to frequent users of EMS services. In other cases, CP appropriate care centers, such as mental health centers, also encompasses alternate destination services under sobering centers, primary care physicians’ offices, or which paramedics who respond to 911 calls transport community health centers. people who meet eligibility criteria to destinations other than an ED, such as a sobering center or a mental This paper provides an overview of state laws governing health crisis center. community paramedicine across the United States, includ- ing laws describing their scope of practice, educational Ultimately, both terms speak to the objectives of reducing requirements, and reimbursement policies. Examining ED overuse, avoiding duplication of health care services, other states’ policies can inform California’s efforts to and meeting the health care needs of vulnerable and build upon its ongoing community paramedicine pilot underserved communities in more pragmatic and cost- project by enacting legislation that would authorize the effective ways. practice of community paramedicine statewide. Legislative Efforts at Defining Terms Regulation: US and California The term “community paramedicine” (CP) may be used Although CP and MIH projects exist in varying forms interchangeably with “mobile integrated health care” across states, with some dating back to as early as 2002, (MIH), but the definitions of these terms are not neces- legislative efforts to recognize and regulate community sarily congruent.1 paramedicine have largely taken place within the last 10 years. Twenty-three states have passed laws that regulate MIH is usually used as an umbrella term that refers community paramedicine, establish CP pilot programs, to multiple types of services provided by emergency or authorize EMS personnel to provide nonemergency medical services (EMS) agencies that go beyond care. Most states with statutory recognition of community $ Six states have ongoing statewide CP pilot paramedicine do not treat community paramedics as a projects made possible through existing stat- separate licensed EMS occupation. Rather, eligible EMS utes. Instead of passing additional legislation or professionals become CP professionals by completing establishing explicit authority in state law, these further training and, depending on the state, receiving states' existing laws governing EMS may grant certification, approval, or endorsement. Most of these EMS agencies broad authority, or allow local enabling statutes contain criteria for training and con- EMS agencies great latitude in determining the tinuing education. Curricula may vary depending on the scope of services that EMS providers may pro- specific EMS agency that a prospective CP professional vide in their respective service areas.4 Authority wants to work for, based on local needs. In addition to to conduct pilot projects may be time-limited. community paramedics, some states also recognize For example, in California, Health Workforce “community emergency medical technicians” and “com- Pilot Projects are intended to support proof-of- munity emergency medical responders” as members of concept studies that can inform debates about the CP workforce. proposals to change laws and regulations that govern the health professionals' practice. California has not passed legislation regulating commu- $ Alaska does not have a statewide CP project nity paramedicine. However, since 2014, California has and has not passed legislation authorizing and operated a statewide pilot project on community para- regulating community paramedicine. However, medicine under the auspices of the Office of Statewide its Community Health Aides/Practitioners (CHA/ Health Planning and Development (OSHPD)’s Health Ps) program, which serves indigenous tribal Workforce Pilot Projects (HWPP) Program. Established communities, contains similarities to community under Sections 128125–128195 of the California Health paramedicine. As frontline health care workers, and Safety Code and Title 22, Division 7, Chapter 6 of CHA/Ps provide culturally relevant emergency, the California Code of Regulations, the HWPP Program acute, chronic, and preventive care in their was founded in 1972 and waives scope-of-practice laws communities, as well as assessing and referring to test and evaluate new and innovative models of care. community members to appropriate health care HWPP #173 is sponsored by the California Emergency resources. CHA/Ps are trained in emergency Medical Services Authority and currently includes 15 medical skills required of all three EMT levels in active CP pilot projects across the state.2,3 the state.5 They are required to enroll in Alaska’s Medicaid program; however, not all of the ser- Summary of Legislative vices they provide are covered by Medicaid.6 Oversight in Other States Below is a summary of different types of state legisla- Medicaid and commercial insurance tion passed that address community paramedicine. See reimbursement Table 2 on page 9 for a list of all US states, as well as the $ In three states, only the Medicaid program District of Columbia and Puerto Rico, and their legisla- reimburses CP services. tive environments.

$ In 12 states, only commercial health plans reimburse CP services. General oversight $ Seventeen states have passed laws authorizing $ In four states, both the Medicaid program and and regulating CP or similar programs (Table 1). commercial health plans reimburse CP services.

$ In 14 states, Medicaid programs reimburse for $ Six states have passed legislation establishing treatment without transport on 911 calls. statewide CP projects and/or working groups to review the feasibility of community paramedicine.

California Health Care Foundation www.chcf.org 2 Professions included in statutes $ Twelve states require prospective CP or MIH personnel to complete additional training. $ Seven states’ laws include only paramedics. The other 10 include other emergency medical Training requirements vary by state, ranging from professions, such as EMTs (basic, intermediate, state-accredited programs to programs set by or advanced), emergency medical responders, individual local EMS bureaus. or other licensed emergency care providers. • Five states require CP personnel to obtain training from an accredited college/university or educational institution. Types of services • Three states are currently developing CP $ Nine states’ laws contain specific language education regulations. outlining the types of services that CP programs or professionals can provide, such as health assessments, chronic disease management, Conclusion hospital discharge follow-up care, and Presently, only one-third of states have enacted MIH-CP medication compliance. legislation. At the same time, community paramedicine is also being piloted in smaller-scale efforts across indi- $ The remaining eight states have “general authority” vidual EMS agencies in additional states. There is great laws, with language stating that CP providers may variation across states in terms of CP providers’ scope provide whatever services are within their scope of of practice, educational requirements, and Medicaid practice as long as such services are authorized by and commercial insurance reimbursement. This varia- a physician or EMS medical director, or are part of tion makes it difficult for policymakers in other states to a patient’s care plan. determine which elements to include in CP legislation. $ In three states — Iowa, Ohio, and Washington — Further research is needed to assess the consequence the passed legislation does not specifically contain of variation in statutory requirements on the diffusion the words “community paramedicine,” “mobile of CP services within states. As California continues its integrated health care,” or other similar language. CP pilot projects, policymakers should look toward the Instead, the legislation authorizes EMS personnel demonstrated benefits of these projects as a guide to to provide care in nonemergency situations, such expanding community paramedicine statewide through as performing medical services within their scope legislative action. of practice or providing community assistance referrals and education services.

Community paramedicine education and licensing/certification

$ Twelve states require formal recognition after training, which varies across states and can be licensure, certification, approval, or endorsement.

• Two states do not require recognition and require only completion of an approved train- ing program.

Left Behind in California: Comparing Community Paramedicine Policies Across States www.chcf.org 3 Table 1. Overview of Recent State Legislation Regulating Community Paramedicine and Similar Programs, by State

State Bill(s) Passed Year Professions Included Education/Training Type of Practice Authority Passed Requirements Recognition

Arkansas HB 1133 2015 Paramedics Completion of training Licensure Services described in a program from accredited patient care plan developed $ Creates a licensure program for community paramedics and college or university by the patient’s physician in allows them to provide services approved by the Arkansas conjunction with the community as directed by a care plan Department of Health paramedic service’s medical director.

Colorado SB 16-069 2016 Paramedics Completion of training Endorsement Medical services including but course from an accredited not limited to initial assessments $ Establishes rules for community paramedic endorsement paramedic training center of patients, care coordination, programs and minimum or accredited college or resource navigation, patient standards for community university, and a passing education, wound closure integrated health care service score on a nationally offered and care, ultrasounds, and agencies exam that is recognized in administration of medications Colorado within the provider’s scope of practice.

Idaho HB 153 2015 Paramedics and EMTs Nothing formally codified in None, besides Community paramedics and the law besides completion recognition of EMTs work within community $ Sets forth definitions of community EMT, community of additional training having completed EMS programs as members health EMS, and community Paramedics and EMTs additional training of community-based teams paramedics in state statute can become “community of health and social services paramedics” and “community providers. EMTs,” respectively, following training.

Indiana SB 498 2019 Paramedics and EMTs In development In development Transportation services, acute care, chronic condition services, $ Allows state Office of the The statute recognizes The statute authorizes the MIH development Secretary of Family and Social both professions as creation of a commission committee to and disease management Services to reimburse EMS being employed by responsible for developing an decide whether services. provider agencies for covered MIH systems, but only MIH program and deciding additional services provided to Medicaid mentions paramedics whether additional training certification is recipients as part of MIH when discussing whether or education is necessary for necessary for additional training paramedics working in the participation in $ Amends statutory definition of EMS to include transportation and certification are program. the program. services, acute care, chronic necessary. condition services, or disease management services as part of MIH

$ Sets standards for establishing and administering MIH programs

California Health Care Foundation www.chcf.org 4 Table 1. Overview of Recent State Legislation Regulating Community Paramedicine and Similar Programs, by State, continued

State Bill(s) Passed Year Professions Included Education/Training Type of Practice Authority Passed Requirements Recognition

Iowa State Code Chapter 147 — Trauma 2016 All EMS providers, Varies by EMS agency None CP providers may perform Care and Administrative Code based on level of The Iowa Department of Certification or emergency and nonemergency Section 641, Chapters 131 and 132 certification Public Health has stated endorsement care without contacting a supervising physician or $ Allows certified EMS providers that under these statutes, is not currently to provide emergency and community paramedicine required for MIH physician designee if the nonemergency care within their would be treated as a systems utilizing tasks are within their scope of scope of practice specialty area of EMS certified EMS practice and fall within clearly with “expanded roles” for providers. written protocols that have providers rather than a new been approved by the service scope of practice. Therefore, program medical director. EMS agencies may provide necessary additional education and training for CP staff to complete required tasks.7

Kentucky HB 106 2019 Paramedics In development Certification (as Community paramedics may advanced practice only practice as employees of a $ Defines community paramedic The bill defines community and mobile integrated health paramedics as advanced paramedic) licensed MIH program. care program practice paramedics that are certified by the Kentucky $ Provides administrative requirements for MIH Board of Emergency Medical Services in the community paramedic emergency medical services subspecialty. The board is responsible for establishing educational requirements, testing requirements, credentialing, and licensure requirements of advanced practice paramedics.

Massachusetts Outside Section 93 2015 Paramedics Training and activities Certification Community paramedics may (Outside determined by the local practice within their scope of $ Defines what MIH is and outlines how it should be administered Section jurisdiction EMS agency and practice and provide follow-up 93), affiliate hospital medical and preventive measures 105 Code of Massachusetts 2018 director including but not limited to fall Regulations (CMR) 173 (105 prevention, vaccinations, health $ Outlines regulations of MIH and CMR screenings, and blood pressure community EMS programs 173) and blood glucose checks.

Left Behind in California: Comparing Community Paramedicine Policies Across States www.chcf.org 5 Table 1. Overview of Recent State Legislation Regulating Community Paramedicine and Similar Programs, by State, continued

State Bill(s) Passed Year Professions Included Education/Training Type of Practice Authority Passed Requirements Recognition

Minnesota State Statute Section 144E.28, 2011 Paramedics Completion of a community Certification Can provide services included Subdivision 9 paramedic training program in a care plan developed by the from an accredited college, patient’s primary physician or by $ Defines what community paramedicine is and what university, or organization an advanced practice registered services community paramedics approved by the state EMS nurse (APRN) or a physician can provide Regulatory Board assistant (PA), in conjunction with relevant local health care State Statute Section 256B.0625, providers. Services must not be Subdivisions 60 & 60a duplicative. $ Addresses what community paramedic services are covered by Medicaid

Missouri State Statute Chapter 190.098 2013 Paramedics Completion of a community Certification Can provide services included paramedic certification in a care plan developed by $ Outlines scope of practice and eligibility requirements of program from a college, the patient’s primary physician, community paramedics university, or education or by an APRN or PA through institution that has been a collaborative practice approved by the Missouri agreement with a physician. Department of Health and Services must not be duplicative. Senior Services or accredited by a national accreditation organization approved by the department

Montana SB 38 2019 Licensed emergency In development Endorsement EMS providers may provide care providers, including out-of-hospital medical services $ Defines community-integrated health care as the provision but not limited to and nonemergency care as of out-of-hospital medical emergency medical determined by board rule. services that EMS providers with responders (EMRs), endorsements may provide as EMTs, advanced EMTs determined by the state Board (AEMTs), or paramedics of Medical Examiners

$ Allows EMS providers to offer community health care in nonemergency situations

California Health Care Foundation www.chcf.org 6 Table 1. Overview of Recent State Legislation Regulating Community Paramedicine and Similar Programs, by State, continued

State Bill(s) Passed Year Professions Included Education/Training Type of Practice Authority Passed Requirements Recognition

Nevada AB 305 2015 EMTs, AEMTs, and Continuing education and Endorsement The following services fall paramedics training that will allow under a CP provider’s scope $ Authorizes and provides for the regulation of CP services the CP provider to meet of practice when they are part endorsement eligibility of a primary care provider’s $ Defines CP services as those and practice within their care plan: evaluation/health provided to patients who do respective scope of practice assessment, chronic disease not require transportation prevention, monitoring to or services at a hospital and education, medication and provided using mobile compliance, immunizations equipment, in a manner that and vaccinations, laboratory is integrated with health care specimen collection and and social services resources lab tests, hospital discharge available in the community follow-up care, minor medical procedures and treatments within scope of practice as approved by the EMS agency’s medical director, home safety assessments, and telehealth.

New Mexico State Statute 7.27.11.8, Part F 2017 Any EMS caregivers Completion of EMS bureau- Authorization Skills include but are not limited approved community EMS (by EMS medical to patient education, home $ Outlines what community EMS programs are and their scope of caregiver course director to (safety) assessments, disease practice perform the skills prevention, immunizations, listed in their developing care plans, fall application as part prevention, referral to of the community social services, acute health EMS program) care issues treatment, and nonemergent transportation. Any skills exceeding the provider’s respective occupation’s scope of practice must be approved through the special skill process.

Ohio HB 64 2015 EMTs, intermediate Not applicable Not applicable May perform medical services EMTs (IEMTs), AEMTs, falling under their respective $ Allows for EMTs, IEMTs, AEMTs, and paramedics to perform and paramedics occupation’s scope of practice medical services that they in nonemergency situations are authorized to perform in if the services are performed nonemergency situations under the direction of their medical director or cooperating physician advisory board.

Left Behind in California: Comparing Community Paramedicine Policies Across States www.chcf.org 7 Table 1. Overview of Recent State Legislation Regulating Community Paramedicine and Similar Programs, by State, continued

State Bill(s) Passed Year Professions Included Education/Training Type of Practice Authority Passed Requirements Recognition

Tennessee SB 1270 2017 Paramedics Specialized training in Licensure Including but not limited to physiology, disease patient evaluation, advice, $ Requires the EMS board to establish standards for a processes, injury and illness treatment directed at preventing community paramedic through prevention, and medical or improving a particular medical promulgation of rules system navigation condition, and referrals to other community resources.

Washington SSB 5591 2015 EMTs, AEMTs, and Not applicable Not applicable Services provided by EMTs, (SSB paramedics AEMTs, or paramedics who are $ Allows EMS to develop community assistance referral 5591), hired by these CARE programs and education (CARE) services 2017 must not exceed their respective programs (HB occupation’s scope of practice. HB 1358 1358)

$ Directs the Washington State Healthcare Authority to develop reimbursement policies for services provided by fire departments pursuant to CARE programs

Wisconsin AB 151 2017 EMS providers, EMTs, Completion of training Approval Community EMS practitioners and paramedics program approved by the may provide services that fall $ Creates an approval process for community paramedics, Wisconsin Department of within their scope of practice, community EMTs, and Health Services are not duplicative of services community EMS providers already being provided to a patient, and are part of the patient’s care plan.

Wyoming Current Rules and Regulations, 2016 EMTs, IEMTs, AEMTs, Completion of a training Endorsement May practice the skills listed Chapter 14 and paramedics (can program approved by the for the individual’s EMS license apply to be community Wyoming Department of level and in accordance with $ Outlines regulations for community EMS practitioners, EMS technicians Health’s Office of Emergency protocols or standing orders agencies, and education or community EMS Medical Services that is approved by the physician programs clinicians) conducted by a college, medical director of the university, or institution with community EMS agency. an articulation agreement with a college or university, or an education program accredited by the Committee on Accreditation for the EMS Professions

Sources: National Association of State EMS Officials (NASEMSO) State Status Re-Assessment: Community Paramedicine-Mobile Integrated Healthcare (CP-MIH), administered in 2018; author review of individual state statutes and individual state departments of health, public health, medicine, and emergency medical service websites. Notes: CP is community paramedicine. EMS is emergency medical services. EMT is emergency medical technician. AB is Assembly Bill; HB is House Bill; SB is Senate Bill; SSB is Substitute Senate Bill.

California Health Care Foundation www.chcf.org 8 Table 2. Legislative Environment for Community Paramedicine, by State (including DC and Puerto Rico), 2019

Alabama — — Passed legislation authorizing/regulating CP or Alaska similar programs Arizona — — — — Passed legislation commissioning pilot CP projects Arkansas — and/or working groups on CP California — Colorado — — — — Statewide (pilot) CP projects made possible through Connecticut — — existing statutes (Authority to conduct pilot projects may be time-limited.) Delaware — Florida — — Individual CP programs running in various local EMS Georgia — — — — agencies throughout the state Hawaii — Idaho — — — Medicaid reimburses CP services Illinois — — Medicaid reimburses treatment without transport on Indiana — — — 911 calls Iowa — Kansas — — Commercial insurance reimburses CP services Kentucky — — Louisiana — Maine — — — Maryland — Massachusetts — Michigan — — — Minnesota — — — — Mississippi — Missouri — — Montana — Nebraska — Nevada — — — — New Hampshire — — New Jersey — New Mexico — New York — — North Carolina — — North Dakota — — Ohio — — Oklahoma — Oregon — — Pennsylvania — Puerto Rico — Rhode Island — South Carolina — South Dakota — Tennessee — Texas — — — Utah — — Vermont — Virginia — — Washington — Sources: National Association of State EMS Officials (NASEMSO) State Washington, DC — Status Re-Assessment: Community Paramedicine-Mobile Integrated West Virginia — Healthcare (CP-MIH), administered in 2018; author review of individual state statutes and individual state departments of health, public health, medicine, Wisconsin — — — and emergency medical service websites. Wyoming — — — Notes: CP is community paramedicine. EMS is emergency medical services.

Left Behind in California: Comparing Community Paramedicine Policies Across States www.chcf.org 9 Endnotes About the Authors 1. Mobile Integrated Healthcare and Community Paramedicine Janet Coffman, PhD, MPP, MA, is a health services (MIH-CP): 2nd National Survey (PDF), National Association of researcher and professor at the UCSF School of Emergency Medical Technicians, April 12, 2018. Medicine’s Philip R. Lee Institute for Health Policy 2. California Health and Safety Code § 128125–128195, California Studies. Connie Kwong is a research analyst at the Philip Legislative Information, accessed October 21, 2019. R. Lee Institute for Health Policy Studies at the University 3. Chapter 6. Health Workforce Pilot Project Program [22 CCR § 92001–92702], Thomson Reuters Westlaw California Code of of California, San Francisco (UCSF). Regulations, accessed October 21, 2019. 4. Mobile Integrated Healthcare and Community Paramedicine About the Foundation (MIH-CP): 2nd National Survey, National Association of The California Health Care Foundation is dedicated to Emergency Medical Technicians, April 12, 2018. advancing meaningful, measurable improvements in 5. Community Health Aide Program Certification Board: Standards the way the health care delivery system provides care and Procedures, Alaska Community Health Aide Program, to the people of California, particularly those with low amended September 12, 2019. incomes and those whose needs are not well served 6. State of Alaska Department of Health and Social Services, Alaska Medical Assistance Provider Billing Manual, “Community Health by the status quo. We work to ensure that people have Aides and Community Health Practitioners (CHA/Ps)" and access to the care they need, when they need it, at a "Appendix H – CHA/P CPT, CDT, & HCPCS Codes," 2019; State price they can afford. of Alaska Department of Health and Human Services, "Services Not Covered by Alaska Medical Assistance," (n.d.). CHCF informs policymakers and industry leaders, invests 7. Mobile Integrated Health care and Community Paramedicine in Iowa (PDF), Iowa Department of Public Health, September 2016. in ideas and innovations, and connects with changemak- ers to create a more responsive, patient-centered health care system.

For more information, visit www.chcf.org.

California Health Care Foundation www.chcf.org 10