2022/2023 AMR Annual Report Page 1
2022-2023 Annual Performance Report and recommendation for agreement (#15-097) with American Medical Response (AMR).
Date: 10-31-2023
Background:
The Board of Supervisors approved the County 9 -1-1 Advanced Life Support (ALS) emergency ambulance agreement with American Medical Response (AMR) on January 13, 2015 (item 3-8). The eighth-year performance period of the agreement commenced on July 1, 2022 and finished on June 30, 2023 . According to the terms of the agreement, AMR may submit a written request for a one (1) year “earned extension” each year following the first full year of the agreement. To qualify for the earned extension, AMR must submit the annual performance report to the Riverside County EMS Agency (REMSA), demonstrate compliance with articles of the contract and request the one (1) year earned extension by September 1, of the applicable year. REMSA received AMR’s request accompanied by their annual performance report on September 1, 2023.
The annual performance report must include (1) evidence of compliance with the agreement provisions, (2) achievement of response time performance of at least 91% in all response time zones for at least nine months, (3) evidence of completed system enhancements for the finished year, and (4) a written agreement with REMSA for planned EMS system enhancements for the next performance period. The request may also include a rate increase request to cover the cost of system enhancements for the current year that exceeds $250,000.
DETERMINATION OF CONTRACTOR (AMR) ELIGIBILITY
REMSA has reviewed AMR’s annual report submission and all the contractor requirements, as stipulated in the agreement, for eligibility to receive a one -year earned annual renewal. Additionally, REMSA monitors AMR’s monthly compliance and reports response time performance semi- annually to the EMS Administrative Zone Groups. REMSA utilized the following to determine that AMR has not met the terms of the agreement to grant a one-year renewal:
• 2022/2023 AMR Annual Report
− Exhibit A: Completed System Enhancements: 2022/2023 - (Page 8) − Exhibit B: Planned System Enhancements: 2022/2023 - (Page 9) − Attachment 1: 2022/2023 AMR Compliance Review Matrix
− Attachment 2: 2022/2023 AMR Annual Response Time Report
The AMR Annual Report, Compliance Review Matrix, and Response Time Report supply the information collected by REMSA to determine AMR’s compliance with the agreement provisions. The performance period reviewed by REMSA is the eighth year of the agreement, which ran from July 1, 2022, through June 30, 2023. The following summarizes key performance areas of the agreement during that performance period. 2022/2023 AMR Annual Report Page 2
RESPONSES, TRANSPORTS, AND COMPLIANCE
AMR responded to 207,005 Emergency Medical Service (EMS) 9 -1-1 calls during this performance period and transported 155,093 patients to hospitals (74.9% transport percentage). Compared to the previous performance period, this was a 7.1% decrease in 9-1-1 response volume and a 1.2% decrease in patient transport. Ambulance response and transport volume were decreased throughout this performance period.
Period Total Responses Transports Transports with APOD Transport (%) 2022 105,646 78,455 21,114 74%
Quarter 1 52,671 39,124 9,793 74%
Quarter 2 52,975 39,331 11,321 74%
2023 101,359 76,638 19,308 75%
Quarter 3 50,399 38,104 10,306 75%
Quarter 4 50,960 38,534 9,002 75%
Grand Total 207,005 155,093 40,442 74.9%
Refer to attached AMR Annual Compliance document.
OPERATIONS AND EMERGENCY MEDICAL DISPATCH
3.1.3 Advanced Life Support (ALS) Mandate - Contractor shall place an ALS ambulance on scene for every request. for emergency medical services, unless otherwise authorized by REMSA through an approved Emergency Medical Dispatch (EMD) and resource response program that dictates level and priority of ambulance response. The ALS mandate may be suspended by REMSA either directly or by policy/protocol during a Multiple Casualty Incident (MCI) response.
AMR continues experiencing the inability to respond to certain ALS mandated calls due to recruitment and staffing challenges that persist after the COVID-19 pandemic. REMSA authorized a BLS response model to low acuity Omega and Alpha EMD calls only.
Emergency Medical Dispatch covers approximately 96% of the C ounty including all Riverside County Fire resources and dispatched agencies including but not limited to: Calimesa Fire, Canyon Lake Fire, Pechanga Fire, Soboba Fire, Morongo Fire. The municipal Fire departments have approved EMD programs including Corona Fire, Riverside City Fire, and Murrieta Fire and Rescue. This gives AMR wide discretion to execute that agreement to strategically dispatch BLS resources to low acuity calls across the County.
During the sample research time during the performance period, AMR has been unable to consistently meet the requirements of the ALS mandate and BLS resources respond above the tier of Omega and Alpha EMD calls. This is not in compliance with section 3.1.3 ALS mandate of the contract. AMR responded 6892 BLS resources to 911 emergency requests between the months of January and June 2023. Of these, 5746 were classified as approved EMD Alpha and Omega responses. 1,146 responses were deemed non-compliant of the ALS Mandate or 16.6%.
Compared to the previous performance period, AMR has demonstrated a significant increase in compliance with BLS utilization in the 911 environment.
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CLINICAL DATA COLLECTION AND REPORT
During this performance period, AMR submitted 243,067 records compared to 237,307 of the last performance periods. This marks a 9 % increase from the previous year in ePCRs to the Riverside County EMS Information System (REMSIS) for review and analysis.
Performance Period AMR - Desert Cities AMR - Hemet AMR -Riverside Quarter
1 Jul-22 3553 4205 12790
Aug-22 3752 4580 13034
Sep-22 3502 4328 12742
Quarter
2 Oct-22 3532 4177 12886
Nov-22 3550 4385 12916
Dec-22 3706 4430 13006
Sub Total Quarter 1 and 2 21605 26105 77374
Quarter
3 Jan-23 3450 4191 12443
Feb-23 3245 3855 11487
Mar-23 3479 4156 12857
Quarter
4 Apr-23 3439 4045 12354
May-23 3383 3981 12577
Jun-23 3162 3720 12159
Sub Total Quarter 3 and 4 20158 23948 73877
GRAND TOTAL 41763 50053 151251
The AMR records collected by REMSA were submitted to the California EMS Authority (EMSA) for inclusion in the California EMS Information System (CEMSIS) to improve Statewide decision-making related to public health concerns such as COVID-19, Ebola, MX, influenza like illness, and respiratory syncytial virus. REMSA also included AMR’s data in the California Core Measures report for 2022.
WORKFORCE SATISFACTION AND TURNOVER
AMR’s turnover survey results were reviewed and verified by REMSA staff. AMR employee turnover by a quarter Month Jan Feb March April May June
Total Responses 18877 17,303 19,140 18,932 18,949 18,297 Total BLS Responses 1506 1,131 1,039 1,110 1,081 1,025
EMD approved (Omega,
Alpha)
978 981 905 934 993 955
EMD-Beta, Charlie, Delta,
Echo
304 97 78 104 56 33
EMD-NA 224 53 56 72 32 37
Total Non-Compliant BLS
Responses to Mandate
528 150 134 176 88 70
Percent of Non-Compliant
BLS Responses to Mandate
35.1% 13.3% 12.9% 15.9% 8.1% 6.8%
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during the performance period was July-Sept 8.5%, Oct-Dec 6.3%, Jan-Mar 8.0%, and Apr-Jun 7.2%. The top 3 primary reasons for separation, according to survey results provided to REMSA , were: Job with the Fire Department 19%, career advancement 14%, and seeking other employment 20%.
AMR Employee
Turnover
2019-20 2020-21 2021-22 2022-23
Q1 9.8% 7.3% 10.1% 8.5%
Q2 5.5% 6.3% 7.3% 6.3%
Q3 6.3% 7.2% 8.4% 8.0%
Q4 5.1% 9.6% 8.0% 7.2%
Turnover has decreased compared to the previous review period. AMR continues to escalate recruiting and retention strategies. AMR continued to offer paramedic scholarships, sign- on bonuses, paramedic upgrade bonuses, and in certain locations relocation bonuses to attract candidates. During this performance period “career advancement” was the number one cause of turnover. Typically, “ Seeking Other Employment” is the primary cause for turnover.
EMPLOYEE INJURIES AND EXPOSURES
During the performance period July 1, 2022 – June 30, 2022 The most common cause of employee injury or exposure was:
Exposure to Infectious Disease: 13%
Sprains/Strains: 48%
AMR continues to utilize a patient satisfaction survey that is conducted by a third -party vendor, “EMS SURVEY TEAM.” A percentage of patients are randomly selected and surveyed each month. The data is analyzed, and the vendor generates the reports monthly and or quarterly by operational division. The reports include customer satisfaction scoring relating to dispatch, ambulance cleanliness, personnel competency, and office performance including billing and customer service metrics. The report also includes AMR’s overall mean score and performance compared to similar companies of size and complexity.
AMR customer satisfaction was at or above the average satisfaction metric for comparable EMS operations in neighboring jurisdictions. AMR continues to perform above those established benchmarks by the third -party company conducting the research.
AMR Riverside County drove 6,920,519 miles in the performance period July 1, 2022 – June 30, 2023. The fleet experienced 19 at fault vehicle contacts during the period resulting in 364,237 miles DRIVEN per at fault vehicle contact. This is a 7.64% increase in miles driven per contact compared to the previous year. AMR has had their fleet equipped with Drive Cam for several years, which is a vehicle monitoring system to help us in identifying risky behavior and through coaching and counseling, changed driving habits that have been shows to reduce incidents.
CUSTOMER SERVICE AND PATIENT SATISFACTION
VEHICLE PERFORMANCE AND SAFETY
2022/2023 AMR Annual Report Page 5
REMSA has developed at the request of AMR a program that identifies individuals who are repeated heavy users of 9-1-1 services. This effort identifies individuals who may benefit from alternative services or education that would lessen the use of the 9-1-1 system due to chronic medical conditions. Additionally, it identifies opportunities for improving EMS system efficiency and reducing costs.
The process is completed through electronic patient care records (ePCR) demographics fields. Variation in patient names were accounted for using the Soundex module that converts patient names into numerical representation and compares for similarity. Examples, Stephanie or Stephany or Stephani will be matched to the same patient with matching last name and DOB.
Raw data during the review period has identified 23 patients that have individually exceeded 100 activations of the 911 system. In the upcoming year, AMR has committed to coordinating with REMSA and DPSS to support establishing an outreach program that will assist in evaluating the ability to connect these high frequency users with secondary services more appropriate to their needs.
SERVICES FOR MENTAL HEALTH PATIENTS
AMR Riverside 5150 transports by Zone for the performance period July 1, 2021 – June 30, 2022.
EMS Zone Transports Percentage of Total
Northwest Zone 2367 26.64%
Central Zone 1535 17.28%
Southwest Zone 917 10.32%
San Jacinto/Hemet Zone 1030 11.59%
Pass Zone 379 4.19%
Mountain Plateau Zone 7 .08%
Desert Zone 2562 28.84%
Palo Verde Zone 95 1.07%
Total Transports 8885 100%
AMR provides ambulance transportation for mental health patients placed on Welfare and Institutions Code (WIC) 5150 (hold for gravely disabled individuals). These patients are transported from the field at the request of law enforcement or between facilities at the request of the Riverside University Health System (RUHS) Behavioral Health Department.
5150 transports were down by 77 transports over last performance period. AMR through system enhancement is working with Riverside University Behavioral Health to develop a crisis response unit to aid officers in no writing 5150’s and transporting patients to voluntary treatment centers instead of General Acute Care Hospitals.
23.03% of Mental Health transports were from law enforcement/fire agency requests, the majority were from HIGH USERS OF 9-1-1 SERVICES
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healthcare facilities.
COMMUNITY EDUCATION AND INVOLVEMENT
During this performance period, AMR provided 1464 hours of community education and support across Riverside County.
Public Education Hours Tactical Support Hours
NW Zone: 137 Riverside County Sheriff 745
SW Zone: 51.5 Hemet Police/Murrieta 10
San Jacinto/Hemet Zone: 263.5 FBI 30
Pass Zone 69.5 US Marshal and CHP 10
Mountain Plateau Zone: 0 Desert SWAT 20
Desert Zones 234.5
Central Zone: 365.5
Palo Verde Zone: 17
Riverside County: 1138.5 Total TEMS Hours 815
Subtotal 1138.5 Subtotal 815
GRAND TOTAL 1,953.50
FINANCIAL PERFORMANCE
AMR’s fiscal year runs concurrently with the calendar year, making financial reporting by AMR’s fiscal year misaligned with the agreement performance period. However, throughout the performance period, REMSA receives preliminary quarterly financial statements. For AMR’s fiscal year 2022, AMR provided an audited annual financial statement to REMSA for review. The financial statement reported net revenue of $11 4,155,470 and operating expenses of $98,637,334. Earnings before income tax and interest were $ 870,367; taxes were $249,806; and total profit was $620,561. Total profit as a percentage of net revenue was 0.005%.
2016-2021 2016 2017 2018 2019 2020 2021 2022
Net Revenue 124,368,557 130,288,845 136,181,476 109,302,915 102,089,706 113,219,232 114,155,470 Operations Expenses 116,471,640 120,902,826 133,346,722 91,437,449 92,893,864 97,433,807 98,637,334 EBITDA 7,896,917 9,386,019 2,834,754 17,865,466 9,195,842 15,785,425 870,367 Taxes 4,662,320 3,841,039 799,974 5,008,554 2,575,640 4,422,650 249,806 Profit 3,234,597 5,544,980 2,034,780 12,856,912 6,620,202 11,362,775 620,561 Revenue % 2.50% 4.30% 1.50% 11.80% 6.50% 10.04% 0.005%
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SERVICE RATES
Per Exhibit 13 of the agreement, AMR has requested a rate increases as the Ambulance rate of 6.38% for the current performance period from the previous year. The rates below as follows:
2021/2022 Rates 2022/2023
ALS and BLS Rate 2,028.71 2,373.74
Mileage 49.33 57.72
Oxygen 211.00 246.88
Night Charge 230.72 269.96
Dry Run with Patient Care 315.32 368.94
RATE INCREASE FOR PLANNED SYSTEM ENHANCEMENTS
The terms of the current agreement require that AMR provide the first $250,000 in annual system enhancements at their cost and may request a rate increase to cover the balance of the cost of the agreed-upon system enhancements. REMSA negotiated the PLANNED system enhancements to be completed by AMR during the 2022-2023 performance period. AMR has requested a 9.99% increase based on the area consumer price index of a 8.7% as determined by the US Bureau of Labor and Statistics and published on their website.
SUMMATION
REMSA has concluded review of the annual performance report from American Medical Response (AMR). AMR has shown significant improvement s in previously identified areas of deficiency throughout this performance period. However, during this performance period AMR has failed to meet the required compliance thresholds of 91% in all EMS Zone’s and subzones for more than nine (9) nonconsecutive months of the performance period.
Therefore, REMSA is unable to grant AMR the requested annual renewal.
The current Ambulance 9-1-1 Advance Life Support (ALS) Ground Ambulance Service contract remains in effect until June 30, 2026.
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EXHIBIT A:
COMPLETED SYSTEM ENHANCEMENTS (2022/2023)
CONFIRE Inland Empire Public Safety Operations Platform (IE PSOP) AMR will endeavor to transition to the CONFIRE Inland Empire CAD to CAD Hub which will allow for the rapid transmission of Computer Aided Dispatch data to all participating departments. The ability to receive data directly through a CAD-to-CAD interface saves valuable time in the dispatching process by eliminating unnecessary phone calls. Additionally, the CAD-to-CAD interface will allow AMR to receive EMD determent codes from participating departments that are using emergency medical dispatch procedures.
Behavioral Health Response Unit
AMR, in cooperation with Riverside County Behavioral Health has reached an agreement for a 5150- response unit. This unit is utilized as a scene response unit to law enforcement to avoid the 5150 and transport the patient to a voluntary treatment center to avoid unnecessary hospitalizations. This program is staffed by an EMT and a Clinical Therapist. The vehicle and EMT have been supplied by AMR and the Clinical Therapist are funded by Behavioral Health.
System Improvements with Ongoing Costs
AMR Mobile Training Unit
AMR has placed into service a mobile training unit with a high-fidelity manikin used to simulate more realistic training scenarios. The MTU will be offered to all community partners as well as AMR personnel.
The unit also contains cameras and monitors to allow students to watch interactions while outside of the vehicle to enhance the student experience. Further it is stocked with 2 CPR manikins designed to test and provide feedback to healthcare professionals on effective CPR. This unit was used several times during the review period of 2022-2023.
Cost: $15K annually
AVL Program
AMR continues to support the closest unit response program outlined by REMSA by providing to Idyllwild Fire Protection District AVL devices to track their vehicles to aid in the implementation of the program.
AMR has a reduced revenue of approximately $178,000 annually to support the program plus an additional $3,600 in annual costs related to the upkeep of the AVL systems.
Cost: $181,600 annually
Citizen CPR Training
AMR has dedicated Two (2) Citizen CPR training units to the fleet. These units are fully stocked with all supplies necessary to conduct Compression only training to any group or organization. AMR has hired a full time CPR coordinator to do community outreach and schedule training classes, including a dedicated CPR hotline for scheduling classes. AMR has trained thousands of citizens with this program in Hands only CPR as a part of our no cost Citizen CPR Training program. The ongoing annual costs of this program include $50,000 in Coordinator costs + $60K in instructor costs, materials, and vehicle maintenance.
Cost: $110,000 annually
Behavioral Health Response Unit
AMR, in cooperation with Riverside County Behavioral Health has reached an agreement for a 5150- response unit. This unit will be utilized as a scene response unit to law enforcement to avoid the 5150 and transport the patient to a voluntary treatment center to avoid unnecessary hospitalizations. This program is staffed by an EMT and a Clinical Therapist. The vehicle and EMT have been supplied by AMR 2022/2023 AMR Annual Report Page 9
and the Clinical Therapist will be funded by Behavioral Health. There has been a delay in putting the unit in service while the county develops protocols and procedures. The unit will be in service as soon as staffing is secured by Riverside County Behavioral Health.
Cost: $90K annually
EXHIBIT B:
PLANNED SYSTEM ENHANCEMENTS (2023/2024)
Patient Follow Up Program
AMR shall work with REMSA and other stakeholders to develop a program under which follow up will occur with patients who are high frequency users of the EMS system and others who may benefit from follow up after engaging the EMS system, linking the individual with appropriate resources for their underlying medical, mental health, and social needs.
Cost: TBD
Span of Control
To improve span of control, and to meet administrative and operational needs more effectively within the Riverside Operation, AMR will hire additional leadership team members and administrative positions with operational oversight may include the Southwest and Central zones.
Cost: +/- $250,000
Additional Unit Hours
AMR will add over 1000 additional ambulance unit hours weekly throughout the County aimed at the continual improvement of 9-1-1 ambulance response times. Continuous analysis of system demands will be monitored and scheduled unit hours will be adjusted as necessary to better maintain system compliance.
Cost: TBD