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1a. EMS Funding Report and RecommendationEMS Funding Report and Recommendation The City of Kalispell 4/24/2014 Produced by: Doug Russell Dave Dedman Jon Campbell F. Ray Ruffatto Doug Schwartz Greg Daenzer 1IPage Executive Summary As part of the Fiscal Year 2014 budget process, it was identified that there would be financial difficulties with several of the funds in the City of Kalispell budget. One of those funds identified was the Emergency Medical Service fund. This fund provides ambulance response and transport within the City of Kalispell. During the budget discussions, it was noted that we were doing an internal analysis of options that can be found in the industry, options that have been suggested, and options that other communities in Montana have undertaken for funding of emergency response. Through this process, working with the local unit of the International Association of Fire Fighters, we have reviewed 6 different options and are recommending an alternative that we believe provides the best service to the residents of the City of Kalispell. This recommendation also provides the residents of Kalispell a direct opportunity to agree or disagree with this recommendation as it involves an election for a dedicated mill levy for the provision of Emergency Medical Services. After almost a year of meeting and reviewing funding alternatives, the committee is recommending that the Kalispell City Council pass ballot language to give the residents of Kalispell an opportunity to vote on a dedicated mill levy of 18.4 mills. This would remove the general fund subsidy that is stressing general fund operations, provide for capital equipment replacement, and provide an increase in staffing to reduce the amount of calls that are being covered by neighboring jurisdictions. While this is not an easy request to make, it is an option that other municipalities in Montana have made for the provision of various aspects of emergency response (see option 4). Most importantly, this option provides the community an opportunity to participate in deciding the level of service they would like to see in their community. 2 1 P a g e Introduction/Background During the Fiscal Year 2014 budget development process, it was identified that the current appropriation process provides a general fund subsidy of approximately $268,000. This subsidy impacts the City of Kalispell in 2 ways: 1) General fund operations are being required to defer capital and operational improvements as general fund revenues are being transferred to the EMS special revenue fund 2) It is difficult to divert additional funding to the EMS fund for capital and operating costs when it is already placing a burden on the general fund departments These two realities leave both entities lacking in resources that could be put to use to enhance both general fund and EMS operations. Since the development of the FY2014 budget, we have been working with the Fire Department and local IAFF employee union leadership to identify options for addressing this situation, knowing that the longer we delay, the more difficult it will be to implement any potential strategies. As such, we have looked at multiple options in operational activities and funding strategies with the hope of presenting a mutually acceptable road map for the future. As part of this review, and to begin the analysis, it is important to understand our current funding and staffing activities. FUNDING The EMS fund is considered a Special Revenue fund as it derives the majority of its funding from operational activities. The total budget for expenses in Fiscal Year 2014 is $968,919. Of that, about $590,000 comes from fees for service, $110,000 from the County EMS levy (which is based on call numbers as a percentage of all calls in the County), and about $260,000 from the general fund. An important aspect to note is that currently about 50% of our fees for service are considered uncollectible as they either exceed maximum allowable charges from Medicaid/Medicare, or are from uncollectible private payers. The uncollectible component makes it difficult to simply raise rates, as that will not coincide with a proportionate revenue increase to cover expenditures. 3 1 P a g e The expenditures in the Fiscal Year 2014 budget do not include any capital expenses. With an estimated cost for an ambulance being $170,000, the only way to pay for this would be through additional subsidies from the general fund, which would place additional pressure on the general fund services. It is this awareness that has initiated this collaborative effort to find options for the future and to help define the service levels that the community may desire. STAFFING Staffing for the City of Kalispell Fire and EMS entails employees that provide services in both the fire department and the EMS department. This provides an opportunity to create efficiencies through the joint provision of service. For example, we estimate that we would need a minimum of 9.5 personnel to operate an effective EMS operation. This would include 8 EMS personnel to operate as emergency responders, a manager, and billing operation. By having 8 responders also capable of providing fire services, our department can be staffed with additional personnel. For example, we may have 7 people on shift, instead of 5, which would provide for additional members of the department to respond to a fire call than would otherwise be available. This, of course, fluctuates with EMS calls that are received throughout a respective shift. However, having the additional personnel provides for an enhanced emergency service response. We currently operate 3 shifts of personnel, two staffed with 10 responders and 1 staffed with 9 responders. The challenge of the department is to be able to account for accrued and sick leave with a 10 member shift and have a desired staffing of 8 personnel, minimum staffing of 7 personnel, on duty for each 24 hour shift that is worked. During 2013, the average staffing per shift was approximately 7.5 personnel for all shifts, with the shift breakdown as follows: • A shift average with 10 personnel = 7.67217630854 • B shift average with 10 personnel = 7.72301912568 • C shift average with 9 personnel = 7.25853825137 The breakdown for personnel assignments for staffing of 7 or 8 responders is listed below. Appendix A provides a visual staffing breakdown for staffing of scenarios including 5-10 responders. A 7 member shift provides the following distribution Station 61: Staffing of a fire engine Station 62: Cross -staffing the ladder truck, two ambulances, or the water tender (depending on what is called out first) An 8 member shift provides the following distribution 4 1 P a g e Station 61: Staffing of the Fire Engine and staffing one ambulance Station 62: Cross -staffing of the ladder truck, one ambulance, or the water tender (depending on what is called out first) STAFFING AND CALL RESPONSES Having the minimum staffing level in place is an attempt to provide a department response for calls within the jurisdiction. While mutual aid is a benefit in the jurisdiction, it also means that there is likely a longer response time to initiate care when calls are being responded to from a unit in another jurisdiction. Below is a table identifying the number of times a mutual aid response was dispatched to the City of Kalispell for an EMS call in accordance with the respective staffing level that was on duty. Staffing Mutual aid call out Slow period (8pm to %overall %8pm- Frequency of staffing Sam) mutual aid call Sam (percentage and out number of days) 10 3 1 2% (3) 1% (1) 1% (4) 9 6 3 4% (6) 8% (3) 10% (38) 8 41 10 29% (41) 27% (10) 29% (106) 7 80 23 57% (80) 62% (23) 9% (217) 6 10 1 7% (10) 3% (1) 0 (note that some calls occurred at specific times when staff was at 6 even hough not cheduled) (As a point of reference, the department had 3058 total calls during this time period.) PUBLIC SERVICE Throughout the discussions that have been held, a primary discussion point has continued to emerge in that we are discussing a public service. This has several important aspects to it that should be discussed, and have been discussed in the past, as evident by the passage of the levy for the North Fire Station in 2004. The questions that we have tried to identify and thus create a roadmap for conversation and strategy in the future include: 1) what level of service does the community desire for its EMS operations, 2) what is the community willing to pay for EMS operations, 3) and, what is the best way to provide that level of service? It is understandable that these are difficult questions, and every individual has an opinion when establishing service levels. Our goal was to address some of the suggested alternatives that arise when discussions of EMS funding are brought to the surface, and provide a platform for 5 1 P a g e initiating discussion and a long-term solution related to the 3 questions listed above. As such, the options that follow are presented with the thought of eliminating some of the alternatives, and further pursuing the recommended alternative. 6 1 P a g e Options This review identified 6 options for consideration. While it is not exhaustive, it did look at the most likely options for our community based on professional experience in the field. Each option tried to provide comparable jurisdictions, a summary review of the option, pros and cons, and a recommendation. It is important to note that the alternatives were reviewed with an objective of eliminating some options prior to further review, knowing that extensive analysis could be spent on an option that will likely be dismissed at the onset. Thus, our effort was to provide a recommendation to move forward without spending considerable time on the research of some options, as the surface review appeared to be enough to make a recommendation. The options that were reviewed were as follows: 1. Combining emergency services (Fire, EMS, and Law Enforcement) into one department 2. Privatizing EMS services 3. Maintaining current level of services and budgetary appropriations 4. Increase service delivery and improve budgetary appropriation subsidy through a voter approved mill levy ballot issue 5. Incorporate dynamic staffing techniques to improve service delivery and/or reduce expenditures in personnel costs 6. Reduce operating costs through the closure of Station 62 Each option is discussed more thoroughly in the following pages. 7 1 P a g e Option 1 Option: Department of Public Safety Description: Establish a multi -service department for emergency responders with employees serving roles throughout the emergency service spectrum including police, fire and medical response. Comparison Jurisdictions: Ashwaubenon, WI; Beverly Hills, MI; Farmington, MI; Oak Park, MI; Kalamazoo, MI; Sunnyvale, CA Synopsis: A public safety department would combine fire, police, and ambulance response into one entity. It may by comprised of personnel serving different functions (e.g. dedicated to police work, firefighter, or EMS) with one public safety director, or it may consist of public safety personnel who each perform all three jobs interchangeably. In order to implement the second type of Department of Public Safety in Kalispell, all fire and police personnel would need to be cross -trained in all three fields. The comparison jurisdictions noted above do not provide ambulance transport, unlike the City of Kalispell. That issue alone makes it difficult to compare with these jurisdictions. In 1971, a study by W.M. Cunningham showed no known jurisdictions have actually reduced its total fire and police budget through consolidation. Furthermore, a Ryland Research study of consolidated departments showed higher fire loss, more civilian injuries or death per fire, more fires per capita, and more uniformed injuries and death per fire. In looking at these reports, combining emergency services departments into one entity has not proven to be a money saver for communities. When it comes to "more service," consolidation seems to be a roadblock to efficiency more than anything. The resulting combined agency may suffer from inadequate training as training demands for non -convergent job skills compete with one another. Public safety personnel may also succumb to insufficient on-the-job experience. Fire safety programs for the public are generally reduced or eliminated, as found by the Ryland Research study. In the end, the community suffers from a failure to meet the demands for fire and police services. Consolidation increases training costs for all personnel, especially during implementation. Studies have shown that cities fail to recuperate these up -front costs over time. Peoria, IL adopted the program in 1962. They abandoned it in 1970. 8 1 P a g e Dayton Beach, FL realized an increased cost of $908,000 in total public safety costs over seven years of consolidation in 1979 and abandoned the plan. Durham, NC abandoned their consolidated department in 1985 after 14 years, citing longer response times, inadequate in-service training, and insufficient pre -fire planning. The International Association of Fire Fighters, the International Association of Fire Chiefs, the National Fire Protection Association, and the International Union of Police Associations have all come out publically against public safety departments. Pros: Cons: - Cross -trained personnel - Potential cost savings- a much more detailed analysis would need to be performed to address this - Higher costs of training Fire/EMS Personnel in Law Enforcement and Law Enforcement in Fire and EMS. - Challenge to allocate timing for maintaining the higher level of specialized training for the respective services. - Potential higher costs, as seen in cited municipalities - Potential to be understaffed as an ambulance transport call could take out a responding unit for a significant period of time. Conclusion: Merging the operations of Fire and EMS with Law Enforcement is a complicated effort, especially with our level of EMS response. Analysis of the financial impacts would require additional study and review which surpasses the scope of this analysis. On the surface, it appears that consolidation would not provide desired results and would have additional negative impacts in service delivery. Consolidation of Fire and EMS with Law Enforcement presents a challenge to the effective completion of any of the three duties that would be identified in Kalispell. In many jurisdictions Fire and EMS exist as separate entities. In Kalispell, having these two departments together provides for some of the benefits of consolidation. However, combining this with Law Enforcement would require a substantial amount of training for the respective duties and take away from the actual field based application of duties. There are no known Fire/EMS/Law Enforcement operations in Montana at this time. This would be a dramatic shift in service delivery, which may be unnecessary depending upon the feasibility of other options. 9 1 P a g e Recommendation: It is not recommended that Kalispell pursue a consolidation of Law Enforcement with our Fire and EMS operations. 101Page Option 2 Option: Privatization of EMS transport services Description: Instead of operating an Emergency Medical Response transport service, this operation would be left to the private sector or contracted out to an outside service providers. Comparison Jurisdictions: Numerous Synopsis: When researching this option it was found that privatization of the EMS transport service works in many jurisdictions. However, it is also important to look at our specific demographics and how they compare to the successful jurisdictions. The City of Kalispell and surrounding area are designated as a super -rural area. The city population is estimated at 20,000 individuals per the last Census, with an overall population of Flathead Valley at 80,000 individuals. There are unique challenges for rural communities that are important factors in the overall EMS system design. Compared to urban locales, rural communities are characterized by large geographical density, lower call volume and larger travel distances. While rural providers generally have lower cost per unit hour than their urban counterpart's for a variety of reasons, their cost of readiness is an even greater mainly due to the fact that EMS responses and transports will take the responding unit out of service for a greater amount of time. According to the American Ambulance Association report, "EMS Structured for Quality," even the best managed EMS systems need a minimum population base of 200,000 users to reach the breakeven point, mainly due to the reduced ability to collect fees for service, whether private pay or government un-subsidized fee payment structures such as Medicare. If the city of Kalispell was to use a private or contracted EMS transport service, it would affect the Fire Departments ability to staff accordingly. We would lose approximately $600,000 in revenue used to pay full time employees which are cross -trained and job share fire department duties. Without the added, cross -trained personnel funded from the EMS budget, the fire department would have fewer people to respond to and operate a fire response event, which in turn would lower the level of service to the community. For example, if we were able to find a private operation to offer services, we would still need to provide fire protection. Assuming we need to man the two fire stations, we would need a daily staffing of 8 people per shift to account for vacation and sick days. This would provide for a geographic response of an apparatus that can prepare the scene for attack upon arrival of the manpower on the second unit, thus leveraging each station's response to limit staff at each station, yet reduce the overall response time from each station. This scenario would allow us reduce overall staffing by 5 responders and 1 administrative personnel for a total of 6 people. As we are currently allocating 9.5 people to the ambulance fund, based on what it would take to operate two responding units, we would end up adding 3.5 people to our fire department allocation. Assuming a total personnel cost of $81,000 (based on FY2014 averages) per person, the additional cost to the fire department budget III Page would be $283,500 per year. This would be higher than the current subsidy of the ambulance fund ($264,000), which demonstrates an approximate equal financial component based on current staffing measures. Adding in the capital component to the current subsidy ($48,500- two apparatus on a 7 year rotation), the subsidy increases to $312,571. Thus, if we could find a provider to take over EMS operations, without any subsidy from the government, the annual savings would be estimated at $29,071. Pros: Cons: - Savings of approximately $29,000 per year (assuming there wouldn't be any fiscal guarantees associated with a contracted service arrangement.) - Plus, Reduced Workers Compensation- savings not calculated yet (likely won't be significant - National research indicates it may be difficult to find a purely market driven operation for a community of our population. There would likely be a lack of competition for the service. - Profit driven enterprise would strive to reduce expenditures, not as a measure of efficiency, but as a profit motive- (it would remove the consideration of EMS service as a public good). This could yield reduced level of care. - Reduced personnel for fire response - Increased dependence on mutual aid - Reduced ability to staff a timely and effective response for the Hazardous Materials Response Team (we would likely have to forfeit the team which would mean no coverage for our part of the state - Reduced ability to staff a response for Technical Rescue Operations (such as confined spaces, which requires 7 members) while maintaining standard operating response Conclusion: If a provider could be engaged that would offer the service on a purely market driven approach, privatization would result in the City of Kalispell removing this cost center and the general fund transfer. However, the reduction would not exist in a vacuum. The City of Kalispell Fire Department would absorb some of the costs in order to staff both stations. Because of this, the net savings to the general fund would not be $260,000 per year, but rather $29,000 per year. Should this be privatized, the City of Kalispell would lose control over the operations, which are now considered a public good and operates in a fashion to provide citizen/community satisfaction versus a private operation which operates on a net profit benchmark. Recommendation: It is recommended that the EMS operations remain under the City of Kalispell as the savings that could be achieved under the best circumstances would be minimal, and potential costs, both financially and from a service delivery perspective could be detrimental. 12 1 Page Option 3 Option: Maintain current level of service resources Description: Continue operating our EMS program with the current level of resources available Synopsis: In an attempt to look at the option of leaving the service delivery model as it stands today there are some key factors that need to be considered. The purpose for entertaining the idea of changing the funding mechanism would suggest that there is something in need of change. Included below are mostly reasons why going forward without a "fix" would provide additional challenges in the future. Currently KFD is operating at a level that allows for response to the majority of its emergency calls. With that said, there are a number of instances where outside aid is required to fulfill needs of the public. In 2013, 140 calls with 96 transports, were dispatched to adjacent jurisdictions to respond within the City of Kalispell. If the Kalispell Fire Department maintains its current level of service, the frequency of calls covered by outside aid will likely increase with the increased populations and call volume. This requires Kalispell to rely more on outside service providers, including volunteer agencies in surrounding jurisdictions. Every transport that is not provided by Kalispell is revenue that is lost to another service provider. While it is difficult to identify the exact amount that is lost due to the nature of the call, capped reimbursements, and uncollectible accounts, it is estimated that the 96 transports would have generated an additional $50,000 when taking these factors into account. The ambulance fund is considered a special revenue fund and relies heavily on its ability to generate revenue to continue its operations. This is made difficult by its ability to charge and collect fees for service. The balance of the funding needed to operate the ambulance service comes from the general fund. Approximately 63% of its billable revenue comes from government subsidies which only pay a portion of the bill. Approximately 17% are private pay with no insurance. Approximately 20% of revenue comes from private party insurance. Another downside to continuing the current model is the impact of capital costs. It is very difficult to include an adequate and realistic budget figure for capital in a budget that is going to end up in the red at year end. The current model's option of funding capital costs is to rely on the resources of the general fund, which stresses the other departments of the municipality. A revenue source that would take into account a capital outlay component would give more certainty and reliability to maintaining the proper equipment needed to provide services. Pros: 131Page - Maintaining the current service level provides the opportunity to avoid the anxiety related to change in the areas of revenue generation or service level provision - Current budget processes accounts for subsidy Cons: - Continued subsidy from the general fund - Capital equipment will likely depreciate at a higher level than replacement occurs - 140 calls in 2013 were responded to by neighboring agencies, including 96 transports, with a potential loss of $50,000 in revenue Conclusion: While it is anticipated that the next budget cycle or two will have to maintain the operation in its current form, it is viewed as being insufficient to fund the costs associated with the operation, as evident by the subsidy of the general fund. Changes will have to be made in the funding formula or in the level of service delivery. Recommendation: Consider additional options for the City of Kalispell for the provision of Fire and EMS funding and/or service delivery. 14 1 Page Option 4 Option: Establish additional revenue source for improved Emergency Medical Service operations through a dedicated mill levy. Description: Establish a dedicated mill levy for Emergency Medical Services that covers the shortfall between costs and expenditures within the EMS fund to provide for equipment replacement and enhance staffing levels for each shift. Comparison Jurisdictions: Billings, Belgrade, Bozeman, Whitefish Synopsis: With Kalispell's service delivery model of a combined service of fire and EMS, there are few exact comparison municipalities in Montana to identify funding models for this activity, though the City of Whitefish comes close to a similar service delivery model. However, there are several municipalities that have gone before the voters to establish a mill levy to support emergency response activities. In 1999 and 2004, voters in the City of Billings passed ballot issues to support police and fire operations. In 2008, voters in the City of Whitefish passed a ballot issue to provide 24 hour fire and ambulance services through a levy of 24 mills. In 2007, voters in the City of Bozeman passed a ballot issue to provide for additional police officers, additional firefighters, and equipment replacement through levies of 30 mills. In 2007, voters in the City of Belgrade passed a ballot issue to provide for additional police officers and police operations through a levy of 34 mills. A dedicated mill levy to sustain and enhance operations in the Emergency Medical Services appears to be the most advantageous effort for establishing additional revenue for these operations. As EMS billing is a mixture of reimbursements with procedure type rate caps and industry wide write off expectations, it is understood that simply raising rates for EMS activities may yield at best a 50% return for the amount or rates increased. The question for Kalispell comes to the view of asking if EMS services are a public good, and at what level they desire to see this good provided. A benefit to the Kalispell community is that any enhancement to the EMS fund provides increased capabilities for the fire suppression activities as well. 15 1 Page Assuming this operation continues as a City of Kalispell function, a future funding analysis takes into account our current revenue streams and adds a dedicated mill levy to remove the general fund subsidy, provide for capital equipment replacement, and account for additional staffing. The current subsidy from the general fund to the Ambulance fund is approximately $268,000 with staffing at 9.5 people. Ideally, staffing would be increased to an 11 responder shift, which would place 9 responders on duty for the majority of time and would provide an additional ambulance being able to be called into service if needed. This would likely lower the number of calls that currently can't be covered by the City of Kalispell and are turned over to another provider, which equated to 140 calls and 96 transports in 2013. This would cost approximately $320,000 to increase this staffing effort. Equipment within the ambulance fund centers around two apparatus at a cost of approximately $170,000/unit- with a life span of 7 years. This amounts to a capital need of $24,500 a year for one apparatus, and $49,000 a year for two units (the third ambulance would be a reserve unit, capable of being placed into service, but not required to be on the regular rotation schedule). In total, to remove the subsidy currently provided from the general fund, incorporate replacement funding for a 7 year rotation on ambulance units, and increase staffing levels, an estimated 18.4 miIIs12 would need to be generated to enhance the service operations. To maintain current staffing levels and incorporate equipment replacement, the mills would be approximately 9.8. The recommendation on this option is to enhance the staffing to reduce the amount of calls within the City of Kalispell that are rolled to another agency because the Kalispell units are currently occupied on a previous call. Pros: - Increases the probability that EMS calls will be handled by Kalispell EMS, versus rolling to another jurisdiction - Provides a dedicated revenue source to be used for EMS operations - Enhanced EMS staffing also enhances fire department operations based on the service delivery model for the City of Kalispell 1 Mills for the prospective levy are calculated for an average on a 10 year horizon, assuming increases in personnel costs and a mill value of $40,000. The current (2014) mill levy for removal of the general fund subsidy, capital equipment replacement, and enhanced staffing would be 16.2 mills. z 18.4 mills would equal $24.09 for a $100,000 house; $48.17 for a $200,000 house, and $72.26 for a $300,000 house. 161Page - Funds that have previously been used to subsidize EMS operations can be redistributed for other needs (such as fire department apparatus, law enforcement staffing and equipment replacement, or be used for property tax reduction, or a split between uses) - Service delivery level is established by the voters, reflecting the actual desires of the community for the services provided - Ballot issues provide for a means of dialogue within the community related to services provided Cons: - Additional tax on City of Kalispell residents - Vote not to adopt the mill levy may require a transition toward reducing the level of services provided as the community is identifying the level of service desired Conclusion: A dedicated mill levy for EMS operations is an option that would allow the community to decide the level of service it desires. It is a route that other cities in Montana have used for law enforcement and fire operations. The dedicated mill would remove the general fund subsidy, provide for future capital replacement, and improve staffing for enhanced response capabilities. Recommendation: It is recommended that a dedicated mill levy be considered for EMS operations. 17 1 Page Option 5 Option: Incorporate Dynamic Staffing to either reduce expenditures in the Emergency Medical Service program or enhance service response. Description: As a significant component of the department expenditures are made up of personnel costs, this review focuses on implementation of dynamic staffing as a response component. Dynamic staffing can be described as a staffing matrix that coincides with fluctuations in call or work demand. A higher staffing number is on duty at the highest work volume hours and a decreased staffing number on duty when the work volume decreases. Additionally, dynamic staffing, in larger departments, uses geographic dispatching and placement within the community based on times and historic call frequency with the goal of having an ambulance unit effectively patrolling a neighborhood in anticipation of a call. Comparison Jurisdictions: During the review, we could not find a comparable jurisdiction that uses dynamic staffing in the purest sense of the practice. Dynamic staffing options are typically seen in an urban environment with a greater population and a larger departmental work force. The City of Kalispell is considered super -rural with the population base of 20,000. The larger communities have the resources that can handle the fluctuations in higher call load to be able to staff in this fashion. In their respective situations, understaffing leads to a slightly longer delay in responding. In our situation, understaffing leads to calls and transports that are dispatched to other jurisdictions. Synopsis: Upon gathering information in regards to call volume and time of call, we can see fluctuations in the frequency of calls for service and the respective time of day. Notably, we see an increase in work load from the hours of 8 am to 8 pm. Though this information identifies the probability of a prospective call, strictly applying this data will by its very nature lead to occasional understaffing as emergency occurrences are not tied to probability curves, but rather to random occurrence. 18 1 Page 0.6 0.5 > 0.4 0.3 0 a 0.2 0.1 0 2013 Probability for Calls for Service by Hour of the Day Q Q Q Q Q Q Q Q Q Q Q a a a a a a a d d d d d Q rl N M �(1 lD 1� 00 41 rl r-I r-I rl r-I r-I <<<<<<< a a a a a a a a a N N N M t Ln Z N w Q Q Q rN-I r-I N M Ln lO d M O The following scenarios are simply examples of the application of dynamic staffing. More data analysis would be necessary to comfortably apply any scenario, be it an increase in staff, or a reduction in staffing. Scenario 1: As an example of dynamic staffing, personnel could be reduced during the hours of 8 PM to 8 AM, or during days with a historical call load. Currently the fire department will attempt to schedule 8 personnel and staff down to 7 personnel on duty. This allows us to have a dedicated fire engine company staffed at Station 61 and staffing at station 62 to facilitate a ladder company response and also cross staff 2 ALS transports. Should the decision be made to reduce staffing and apply a dynamic staffing principle and we move to a duty staff of a 6 person minimum, we would have the dedicated fire engine company at Station 61, a ladder company response at Station 62, and the ability to cross staff 1 ALS Transport. Looking at the response history, there would be a 20% chance of seeing an ALS call at 1-2 AM. Depending upon how the call is dispatched and the nature of the call(motor vehicle accident would take both units to aid in medical care and scene security), both the engine and the ambulance may respond. If a second call were to occur, however, it would be responded to by a different agency. While the probability graph provides a visual representation of the ability to predict calls, it must be understood that even with the call presentation charted above, there were 140 19 1 'age occurrences in 2013 where a call for mutual aid was requested for the EMS responses. These calls resulted in 96 transports within the City of Kalispell being handled by a non -Kalispell agency. Implementation of the dynamic staffing philosophy would likely create a more efficient manpower to call probability effort. However, it would also likely increase the occurrences of a non -Kalispell agency responding to a call within the City of Kalispell. Scenario 2: Increase staffing to support the need of added work load between the hours of 8 AM and 8 PM. Personnel could work a 12 hour shift to help with the daily duties and also to assist with 911 responses. This would bring staffing levels to 9 personnel during the busiest hours when it is most needed. This would require the equivalent of 3 full time personnel versus 6 full time personnel under the 24 hour structure offering a 50% savings in personnel cost for the additional day time staff. The 9-member shift would provide for staffing of the engine at Station 61, an ambulance at Station 61, cross staffing for the ladder truck and two ambulances at Station 62. Pros: - Allocation of resources to heaviest call volume periods - Has the potential to maximize the scheduling effectiveness of personnel - Has the potential to enhance operational response at lower costs Cons: - Smaller departments that schedule exclusively according to probabilities will find themselves understaffed at respective times and dependent upon neighboring jurisdictions. - Acceptance of a level of risk by the community - Smaller departments may be unable to implement true dynamic staffing components as there is not an inter -departmental backup resource to cover shortfalls Conclusion: Dynamic staffing is a system to allocate staffing based on probabilities of call volumes. There are potential components that are available to the City of Kalispell even though dynamic staffing is more advantageous in larger departments. Recommendation: Assuming that changes will be incurred within the department with either additional financial resources, or reduced financial resources, dynamic staffing may provide for potential cost savings and/or enhanced staffing additions to provide more service capabilities within the City of Kalispell at reduced costs by analyzing call loads and scheduling accordingly. 201 Page Option 6 Option: Reduce expenditures in the current Emergency Medical Service through closure of the North Station. Description: Staffing two stations places an increased cost factor on the program through staffing related functions. This option reviews the potential impacts of closing the north station. Synopsis: The closure of Station 62 as a means of cost savings has two potential routes of implementation. 1. Close the station by moving all personnel, operations, and response capabilities to Station 61. Closure of 62 by moving all personnel, operations, and response capabilities to 61 would result in a reduction in operating costs of the facility. However, these cost savings would be minimal as the facility would still require utilities and upkeep. Moving all operations out of this station would have three primary effects on the operations of the department. Closure of 62 would increase response times, change the department's ISO rating, and possibly alter the department's perception within our community. Increased response times would result due to a lack of personnel in 62's area due to the extended travel time from 61. The Insurance Service Organization rating would likely change the next time the ISO evaluation is conducted. Many factors go into this evaluation including staffing, response times, and proximity of fire stations to the area served. A potential outcome could be an overall change to the ISO rating for the entire City. Another potential outcome could be a split rating with 61's response area receiving one rating and 62's response area receiving another. ISO ratings are used by insurance companies in the evaluation of risk for property owners. A better ISO rating is sometimes used for the calculation of insurance costs for property owners. This typically impacts larger commercial and industrial facilities greater than residential properties. It is not possible to fully evaluate the effects the closure of station 62 would have on the public's perception. However, some factors can be identified. The voting public approved a special assessment for the construction of the station, and they have benefited from the increased service that it provides. Altering our model for emergency services could be perceived as service reduction, increased response time, and reduction in public safety in contrast to a measure that was voter approved. Pros for implementation model 1: 21 1 Page - Reduced operating costs for the facility Cons for implementation model 1: - Increased response times - Likely impact to ISO Rating - Direction opposite of the voter approved project to construct Station 61. Model 2. Close the station and reduce the workforce. Closure of station 62 would have the same pros as in implementation model 1 with the added financial benefit of reducing payroll. From a strictly financial perspective, implementation model 2 would have measurable monetary benefits in tandem with the number of positions the City was willing to eliminate. The cons for implementation model 2 are the same as for model 1 with several important additions. Any reduction in staffing will result in a reduction in service. On a given day, Kalispell Fire Department endeavors to staff a fire engine and 2 ambulances. The personnel staffing the ambulances are used to cross staff a ladder truck. This staffing configuration is designed to utilize the abilities of our Firefighter who are also EMTs or Paramedics to respond to calls for service of various types with the apparatus, tools, and equipment they may be required to use for mitigation of the emergency. A reduction in staffing would mean fewer available resources to respond to calls for service. Fewer resources would reduce the number of ambulance transports the Department would be able to perform, and that would reduce the revenue from these transports. In 2013 we had 140 EMS calls for service within city limits that generated a response from emergency service providers other than Kalispell Fire Department due to a lack of available resources. A reduction in staffing will result in a higher number of incidents requiring mutual aid for calls in the City of Kalispell. Pros for implementation model 2: - Cost savings in operations and personnel Cons for implementation model 2: - Increased response times - Likely impact to ISO Rating - Direction opposite of the voter approved project to construct Station 61. - Lost revenue for call going to alternate agencies - Increase in calls within Kalispell city limits that are not handled by the Kalispell Fire/EMS department 22 1 Page Conclusion: With continued growth on the north end of Kalispell, reducing coverage capacities does not seem to be the best service delivery model. Moreover, the major cost savings would be in the form of personnel reductions, which would decrease the calls being handled by the Kalispell Fire/EMS Department, thus reducing the service delivery and cost recovery for the department. Recommendation: While closing the second station and eliminating the personnel with that station would create cost savings, this option is not recommended as it would directly impact the service delivery that the voters of Kalispell previously voted to achieve. 231Page Recommendations The goal of this review was to find a strategy to lead the community of Kalispell into the future in respect to EMS service delivery. The initiating factor of this review is the financial pressures on both the general fund and the EMS fund, especially considering the need for replacement of ambulance units within the EMS operations. In order to come to a funding solution, the first decision is how to approach the provision of service. Provision of service recommendation: Based on the options reviewed, we think the best option is to continue providing services with the combined departments of Fire and EMS. We think this presents the best and most efficient method of service provision for the residents of the City of Kalispell as there is a professionally trained department staffed to respond to emergency calls in an expedited fashion, with public oversight. Should this be the option, we then need to look at the funding related issues, and determine how to identify a funding mechanism to meet the service delivery recommendations. Staffing Recommendation: Staffing Alternative 1 The first option that presents itself in the management of emergency response is to incorporate a component of Dynamic Staffing and match call loads with staffing levels. Currently, with average staffing being approximately 7.5 personnel, the option would be to reduce staffing during the slower periods where it is not anticipated that two EMS calls would occur. However, it is difficult to say if that would be acceptable to the community, knowing that emergencies are not scheduled and that removing an EMS unit from rotation during these periods would create that situation where a second call would have to be responded to by a neighboring agency. Knowing that we already have a number of calls that are responded to by neighboring agencies demonstrates that this is a reality we are facing. And while introducing dynamic staffing to reduce personnel would provide a data driven staffing, it is likely that additional calls would be outsourced to neighboring jurisdictions. Staffing Alternative 2 (Recommended staffing alternative) A second option is to increase staffing in an attempt to provide services to a level that provides a City of Kalispell EMS response to a resident of the City of Kalispell. In looking at the data, increasing staffing levels to an 11 responder crew with a 9 member shift would increase the 241Page probability of having an EMS unit available for second call. The worst case scenario in this staffing model would have 272 shifts with two ambulances staffed and 93 shifts with three ambulances. This would, however, more than double the department's ability to staff a third ambulance versus the 2013 model in which we had three ambulances staffed on 42 days, or 11.5% of the time. Realistically, using the statistics from 2013, it is likely that our ability to staff a third ambulance would increase to as high as 50% of the year. Under the best scenarios, this model would create only 33 shifts out of the year with only two ambulances staffed, which increases the likelihood of staffing a third ambulance to 73%. Staffing Alternative 3 The final staffing option is to continue with the status of staffing as it is and accept the response levels where they are. While this is an option to consider, it is not the ideal standpoint from a service delivery organization as we know that we are not responding to all the calls in our jurisdiction with one of our response units. Funding Alternatives The alternatives for funding are associated with the options above and are based initially on the combination of looking at the current state of funding, which is what drove us to the review. With the need of additional revenue for the capital replacement and to remove the subsidy from the general fund, it is recommended that a dedicated mill levy for Emergency Medical Service be proposed to the voters with either staffing levels to remain where they are or to increase staffing levels to a position where we would have a greater frequency of being able to respond to call within the city of Kalispell. The City and leadership of the local IAFF have discussed the response should a proposed mill levy fail to pass in an election. A reduction in staffing would be the likely result in order to ease the burden on the general fund. This would have to be coordinated over time with attrition of current employees and an implementation of scheduling to some of the dynamic staffing principles. Alternative 1 (Current Staffing with removal of subsidy) This alternative would provide for the staffing levels to remain as they currently are, yet provide revenue to remove the subsidy and provide funding for capital replacement. With an operating subsidy of $268,000 in FY 2014, and ambulance replacement costs at $170,000 per unit, a mill levy could be initiated in the amount of 9.8 mills a year to cover costs over a 10 year horizon. 25 1 Page Alternative 2 (Increase Staffing and remove subsidy- Recommended alternative) This alternative provides for removing the general fund subsidy, replacing capital equipment, and increasing staffing. The current subsidy from the general fund to the ambulance fund is approximately $268,000. By adding an increase of four responders, we would likely lower the amount of calls that currently can't be covered by the City of Kalispell and are turned to another provider, which equated to 140 calls and 96 transports in 2013. This would cost approximately $320,000 to increase this staffing effort. Equipment within the ambulance fund centers around two apparatus at a cost of approximately $170,000/unit- with a life span of 7 years. This amounts to a capital need of $24,500 a year for one apparatus, and $49,000 a year for two units. In total, to remove the subsidy currently provided from the general fund, incorporate equipment replacement funding for a seven year rotation for ambulance units, and to increase staffing levels, an estimated 18.4 mills would need to be levied to enhance the service operations. Overall Recommendation: In respect to providing the level of service that is most likely to provide a City of Kalispell response to an EMS call, it is recommended that a mill levy election be held to dedicate funding to EMS operations to remove the general fund subsidy, replace ambulances on an appropriate schedule, and hire four additional personnel. The total of this levy would be 18.4 mills.3 3 18.4 mills would equal $24.09 for a $100,000 house; $48.17 for a $200,000 house; and $72.26 for a $300,000 house. 261Page O yea eoo , J "z Cross Staffed J 1O W 0 z a z V) O oc W CL 0 I ;ID LU O �D Q J W W J z z 0 oc w a a w �c a w w z LL z w Q ... SEE now J cross Starred z z 0 w a 00 a w �c a w w z LL z w Q ■.. SEE now J VIT � J rm � ui�u 1 ■.. ... Cross Staffed z z 0 LU 0_ a F41 LU a w w z LL LL z 1 v ■ ■ . SEE on Cross Staffed A � 6 0 ' e Q �D 90�® I �D J N W o �D z Q z V 0 oc w a k.o a Cross Staffed w a w w z U- z z W, k7: 0 _ V) �D I �D ■ �D p 0 .. 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