NASEMSO | Evidence Based Guidelines for Prehospital Pain Management
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Wall Time Toolkit
Extended ambulance patient offload times (APOT), or “wall times,” at hospitals are causing long waits for 911 and interfacility patients and exacerbating the EMS workforce shortage. Ambulance services across the country are continually trying to meet demand with fewer resources; when EMS providers are kept out of service for extended periods of time because they are unable to transfer patient care at the hospital, wait times for both 911 and inter-facility patients increase and both emergency and non-emergency calls pile up.
We recognize that the issue of extended wall times is not new, but an existing problem exacerbated by the ongoing battle with COVID-19 across the country. Increased wall times are a symptom of a much larger problem for which there is no easy solution.
This toolkit will provide an overview of EMTALA, highlight the intersection between EMTALA and APOT, and address some frequently asked questions along with links to resources and examples of how services are addressing this issue across the country.
EMTALA – Emergency Medical Treatment and Labor Act
Summary of Major Provisions
- The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that was enacted as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 U.S.C. §1395dd).
- EMTALA provides that when an individual comes to an emergency department, he/she/they must be stabilized and treated, regardless of their insurance status or ability to pay.
- EMTALA is often referred to as the “anti-dumping” law and was designed to prevent hospitals from transferring uninsured or Medicaid patients to another hospital without, at a minimum, providing a medical screening examination to ensure they were stable for transfer.
- EMTALA requires the hospital to provide a screening examination to determine if an emergency medical condition exists and, if so, provide stabilizing treatment to resolve the patient’s emergency medical condition.
- EMTALA requires Medicare-participating hospitals with emergency departments to screen and treat the emergency medical conditions of patients in a non-discriminatory manner to anyone, regardless of their ability to pay, insurance status, national origin, race, creed, or color.
EMTALA & Ambulance Patient Offloading Times (APOT)
- EMS agencies have been struggling with extended Emergency Department patient offload times. This has been exacerbated over the last few years of the COVID-19 pandemic.
- This has impacted the ability of EMS agencies to provide services and respond to ambulance service requests. Additionally, it is impacting many public safety agencies that are responding to medical emergencies.
- Centers for Medicare & Medicaid Services (CMS) issued a memorandum on extended ambulance patient offload times and EMTALA in July 2006.
- In the memorandum, CMS noted “Many of the hospital staff engaged in such practice believe that unless the hospital “takes responsibility” for the patient, the hospital is not obligated to provide care or accommodate the patient”
- CMS stated that this practice may result in a violation of the Emergency Medical Treatment and Labor Act (EMTALA) and “raises serious concerns for patient care and the provision of emergency services in a community.”
- Additionally, CMS notes that this practice may also result in a violation of 42 CFR 482.55, the Conditions of Participation for Hospitals for Emergency Services, which requires that a hospital meet the emergency needs of patients in accordance with acceptable standards of practice.
- EMTALA defines[1] when a patient “presents” at an emergency department in the following way:
(1) Has presented at a hospital’s dedicated emergency department, as defined in this section, and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual’s appearance or behavior, that the individual needs examination or treatment for a medical condition;
(2) Has presented on hospital property, as defined in this section, other than the dedicated emergency department, and requests examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual’s appearance or behavior, that the individual needs emergency examination or treatment;
(3) Is in a ground or air ambulance owned and operated by the hospital for purposes of examination and treatment for a medical condition at a hospital’s dedicated emergency department, even if the ambulance is not on hospital grounds. However, an individual in an ambulance owned and operated by the hospital is not considered to have “come to the hospital’s emergency department” if –
(i) The ambulance is operated under communitywide emergency medical service (EMS) protocols that direct it to transport the individual to a hospital other than the hospital that owns the ambulance; for example, to the closest appropriate facility. In this case, the individual is considered to have come to the emergency department of the hospital to which the individual is transported, at the time the individual is brought onto hospital property;
(ii) The ambulance is operated at the direction of a physician who is not employed or otherwise affiliated with the hospital that owns the ambulance; or
(4) Is in a ground or air nonhospital-owned ambulance on hospital property for presentation for examination and treatment for a medical condition at a hospital’s dedicated emergency department. However, an individual in a nonhospital-owned ambulance off hospital property is not considered to have come to the hospital’s emergency department, even if a member of the ambulance staff contacts the hospital by telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment. The hospital may direct the ambulance to another facility if it is in “diversionary status,” that is, it does not have the staff or facilities to accept any additional emergency patients. If, however, the ambulance staff disregards the hospital’s diversion instructions and transports the individual onto hospital property, the individual is considered to have come to the emergency department.
[1] 42 CFR § 489.24(b) – Special responsibilities of Medicare hospitals in emergency cases.
APOT Strategies
- EMS agencies who are experiencing extended ambulance patient offload times should engage the hospital leadership to collaborate to identify possible solutions. Often, we assume that the hospital leadership is aware that the EMS crews are being held for extended periods of time. Also, the hospital may not understand how APOT is impacting your organization and the overall EMS and public safety response. Emphasize that EMS is one piece of a larger EMS system.
- EMS agencies should consider educating or reminding the hospital leadership about their obligations under EMTALA.
- Consider placing a transfer coordinator or another member of your staff to stay with patients during the transition between EMS and ED care. The EMS agency is under no obligation to do this and could set a precedent or expectation by the hospital that extended APOT is the EMS agency’s responsibility. However, it may serve to free up valuable EMS resources.
EMTALA & APOT Frequently Asked Questions
- Are EMS personnel required to remain with the patient until an emergency department personnel “accept” report or “takes over care” of the patient?
Answer: No, the EMS crew is not legally required to remain with the patient until the hospital personnel take a report or take over patient care. As the EMTALA provisions above cite, the EMS crew may choose to remain with the patient but, as soon as that patient arrives on hospital property or enters the emergency department, the hospital is legally responsible for the patient.
- What if the patient’s condition requires constant attention and the patient cannot be left alone without causing the patient harm?
Answer: If the patient’s condition dictates that the patient cannot be safely left alone, the crew would have an ethical obligation to continue to care for the patient until care can be safely transferred to the appropriate caregiver. The EMS crew should continue to provide patient care and should contact a supervisor or Officer in Charge (OIC) at their agency to inform them of the situation and request assistance with facilitating the transfer of care.
- What do I do if the emergency department staff fail/refuse to take a report or take over care of the patient?
Answer: The EMS crew should attempt to provide a verbal report to an emergency department staff member if possible. If no one is available, or the hospital staff will not make someone available to take a verbal report, the crew should tell an ED staff member that the EMS crew will be leaving the patient, where the patient was left and the patient’s general condition. EMS providers should document how long they waited after arriving at the ED, where they left the patient, which ED staff member they notified, and the patient’s condition when they left in their patient care report. EMS providers should be sure to leave a copy of their patient care report or an abbreviated patient care report with the hospital staff or with the patient.
In some states, extended APOT may be reportable to the state-level oversight agency, such as the state EMS Office or the Department of Public Health.
If hospitals are unresponsive to the initial conversation, you could also consider escalating the issue to your State Survey Agency, the agency primarily charged with taking EMTALA complaints.
We have created a draft letter for use in communicating with your State Survey Agency; be sure to update the draft letter to include specific examples and data that illustrate the particular issues your service is facing and the steps you’ve taken to try and resolve the issue so far.
- Can I be accused of patient abandonment if I leave a patient in the ED without a member of the ED staff taking over the care of the patient?
Answer: Because the legally becomes the hospital’s responsibility upon arrival on hospital property or upon arrival in the ED, it is highly unlikely that a claim of abandonment could be sustained. The most important thing EMS providers can do is to exercise reasonable care of the patient before, upon, and after arrival at the ED. EMS providers who reasonably attempt to furnish a report to the ED staff or who ensure that the patient can be safely left at the ED with either an abbreviated or full patient care report will likely be protected from liability.
Additional Resources
Best Practices for Mitigating Ambulance ED Delays webinar
California Emergency Medical Services Authority Ambulance Patient Offload Time (APOT) webpage
Statewide Method of Measuring Ambulance Patient Offload Times
State Survey Agency Directory
This is the agency primarily charged with receiving EMTALA complaints.
Wall time Collaborative a partnership to reduce ambulance patient off-load delays
presentation from 2013
In the News:
EMS crews forced to wait hours to drop patients at overwhelmed hospitals
National EMS Advisory Council Meeting Webcast Feb. 9-10
From EMS.gov on January 27, 2022
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NHTSA Names New Office of EMS Director
From NHTSA on January 13, 2022
Long-time OEMS Staff member assumes leadership role
The National Highway Traffic Safety Administration (NHTSA) today announced that Gamunu Wijetunge, NRP, will assume the role of Director of the Office of EMS effective January, 29, 2022.
Gamunu “Gam” Wijetunge, who has worked within NHTSA’s Office of EMS for more than 20 years, is also a volunteer paramedic, fire captain and the president
of a volunteer rescue squad in Maryland. He will assume the director role — which is also responsible for the National 911 Program housed within the Office of EMS — following the retirement of Jon Krohmer, M.D., FACEP, FAEMS.
“For many years, Gam has been a leader within NHTSA’s Office of EMS, an
advocate for clinicians, and a trusted colleague for both Federal partners and Fire/EMS organizations,” said Dr. Krohmer. “His commitment to collaboration within the EMS community may be best illustrated through his stewardship of EMS Agenda 2050, which sets a clear path for the continued improvement of people-centered EMS systems for the next 30 years.”
Throughout his tenure at NHTSA, Gam has played an integral collaborative role in the development of EMS systems nationwide. These include leading efforts to:
- Develop evidence-based guidelines and tackle EMS system improvement issues
- Address recruiting, retention, clinician safety and other EMS workforce topics
- Improve national EMS preparedness through coordination with other Federal agencies
- Facilitate consensus and collaboration within leadership and working groups of the Federal Interagency Committee on EMS (FICEMS).
“I am thrilled to continue the office’s collaborative work side-by-side with our Federal partners, EMS stakeholders nationwide, and my colleagues at NHTSA,” said Gam. “I look forward to continuing Jon’s good work to support state, regional and local EMS and 911 agencies as we strive to advance our people-centered EMS and 911 systems.”
Wijetunge has a Bachelors’ Degree in Emergency Health Services from the University of Maryland, Baltimore County and a Master of Public Management from the University of Maryland, College Park. He has several professional affiliations and has been recognized repeatedly for outstanding performance and federal service, including most recently the HHS/ASPR COVID-19 Pandemic Civilian Service Medal in 2021.
Congratulations to Gamunu Wijetunge, the newly-appointed Director of @NHTSAgov's Office of #EMS! We look forward to continued collaboration to ensure #mobilehealthcare excellence for all Americans. #SupportEMS #NotJustaRide #AlwaysOpen pic.twitter.com/qHO3REmlEk
— AmericanAmbulanceAsc (@amerambassoc) January 13, 2022
Colorado | What it’s like in the day of a Denver Health paramedic
From KDVR on January 3, 2022
DENVER (KDVR) — Denver Health paramedics are often first on the scene of an emergency. And when seconds matter, they make life or death decisions.
FOX31 joined them on a ride-along to see how they do their jobs and how they are holding up during the pandemic.
If you need help, Denver Health paramedics are just minutes away.
In Memory of Bill McCarthy
Many of you have likely heard the devastating news of the passing of Mr. Bill McCarthy, CEO of Coastal Health Systems of Brevard, on December 20, 2021. Bill was a dedicated leader in EMS and a dear friend and colleague to many. He served as the CEO of Coastal Health for 20 years and will always be remembered for the amazing work he did on behalf of Coastal Health and EMS providers in Florida. The American Ambulance Association Board of Directors extends their sincere condolences to Bill’s family, friends, and colleagues. Please see the Memorial Service information below.
Memorial Service for Bill McCarthy
Saturday, January 15th from 2-4pm ET
Beckman-Williamson Funeral Home
5400 Village Drive
Rockledge, Fl. 32955
Jan 5 | EMS360: Fatigue Risk Management in EMS Webtool Demo
Fatigue Risk Management in EMS: Project Summary and Webtool Demo
HRSA Federal Office of Rural Health Policy Updates
From HRSA’s Federal Office of Rural Health Policy
What’s New
HRSA Rural Public Health Workforce Training Network Program – applications due March 18. HRSA anticipates awards for more than 30 community-based organizations that will join an effort to train and place public health professionals in rural and tribal areas. Eligible applicants include minority-serving institutions of higher education, Critical Access Hospitals, community health centers, nursing homes, Rural Health Clinics, substance use providers, and state or local workforce development boards. Each grantee will receive approximately $1.5 million for a three-year project. FORHP will hold a webinar for applicants on Wednesday, January 5 at 1:00 pm ET. For those unable to view online, see the Events section below for dial-in information.
HRSA Rural Residency Planning and Development (RRPD) Program – deadline extended until January 11. The Health Resources and Services Administration (HRSA) revised the program sustainability requirements and extended the deadline for RRPD grant applications. Applicants should review the changes and can resubmit their applications if needed. HRSA will only review your last submitted application. This program aims to increase opportunities for physicians to train in rural residencies. A total of $10.5 million will develop 14 new rural residency programs accredited by the Accreditation Council on Graduate Medical Education (ACGME). Eligible applicants include rural hospitals, GME consortiums, and tribal organizations. For questions, email RuralResidency@hrsa.gov.
HRSA Small Health Care Provider Quality Improvement Program Funding Opportunity – applications due March 21. HRSA will be making approximately 40 awards of up to $200,000 each to support the planning and implementation of quality improvement activities in rural communities. Applicants must be rural domestic public or private nonprofit entities with demonstrated experience serving, or the capacity to serve, rural underserved populations in a HRSA-designated rural area. FORHP will hold a technical assistance webinar for applicants via Zoom on Wednesday, January 26, 2022 from 2-3 p.m. ET. A recording will be available for those who cannot attend.
Share Your Experiences on Rural Emergency Preparedness and Response. The Rural Health Information Hub (RHIhub) wants to hear about how rural communities, health care facilities, public health departments, first responders, tribes, rural serving organizations, and others have had to adapt, collaborate, and innovate in the face of disasters and public health emergencies. They are looking for examples of lessons learned, successes, challenges, or other helpful information to highlight related to emergency preparedness, response, and recovery for a variety of disasters. Examples will be shared in an emergency preparedness toolkit on the RHIhub website.
Spread the Word About Vaccine Boosters. The U.S. Department of Health & Human Services released new resources – posters, flyers, videos, and talking points – to help promote the extra protection from COVID-19 boosters. All vaccinated adults aged 18+ are eligible for a booster. Search by zip code to find nearby locations providing adult and pediatric vaccines and boosters for COVID-19 and the flu at vaccines.gov.
Ongoing: HRSA Payment Program for RHC Buprenorphine-Trained Providers. In June 2021, HRSA launched an effort to improve access to substance use disorder treatment by paying for providers who are waivered to prescribe buprenorphine, a medication used to treat opioid use disorder. Rural Health Clinics (RHCs) still have the opportunity to apply for a $3,000 payment on behalf of each provider who trained to obtain the waiver necessary to prescribe buprenorphine after January 1, 2019. Approximately $1.5 million in program funding remains available for RHCs and will be paid on a first-come, first-served basis until funds are exhausted. Send questions to DATA2000WaiverPayments@hrsa.
COVID-19 Resources
NARHC Assistance with Federal Programs for COVID-19 Testing, Vaccine Distribution, and Provider Relief Fund. The National Association of Rural Health Clinics (NARHC) has background information and guidelines in its collection of technical assistance webinars for all COVID-related programs designated for Rural Health Clinics.
Federal Office of Rural Health Policy Resources for COVID-19. A set of Frequently Asked Questions (FAQs) from our grantees and stakeholders.
Rural Health Clinic Vaccine Distribution (RHCVD) Program. Under the program, Medicare-certified RHCs will receive direct COVID-19 vaccines in addition to their normal jurisdictions’ weekly allocation. Contact RHCVaxDistribution@hrsa.gov for more information.
Community Toolkit for Addressing Health Misinformation. The new resource asks for participation from individuals, teachers, school administrators, librarians, faith leaders, and health care professionals to understand, identify, and stop the spread of misinformation. The toolkit includes common types of misinformation and a checklist to help evaluate the accuracy of health-related content.
Online Resource for Licensure of Health Professionals. As telehealth usage increased during the pandemic, FORHP funded new work with the Association of State and Provincial Psychology Boards to reduce the burden of multi-state licensure. The site provides up-to-date information on emergency regulation and licensing in each state for psychologists, occupational therapists, physical therapists assistants, and social workers.
HRSA COVID-19 Coverage Assistance Fund. HRSA will provide claims reimbursement at the national Medicare rate for eligible health care providers administering vaccines to underinsured individuals.
HHS Facts About COVID Care for the Uninsured. The U.S. Department of Health & Human Services (HHS) helps uninsured individuals find no-cost COVID-19 testing, treatment, and vaccines. The HRSA Uninsured Program provides claims reimbursement to health care providers generally at Medicare rates for testing, treating, and administering vaccines to uninsured individuals, including undocumented immigrants. There are at-a-glance fact sheets for providers and for patients in English and Spanish.
CDC COVID-19 Updates. The Centers for Disease Control and Prevention (CDC) provides daily updates and guidance, including a section specific to rural health care, COVID-19 Vaccination Trainings for new and experienced providers, and Tips for Talking with Patients about COVID-19 Vaccination.
HHS/DoD National Emergency Tele-Critical Care Network. A joint program of the U.S. Department of Health & Human Services (HHS) and the U.S. Department of Defense (DoD) is available at no cost to hospitals caring for COVID-19 patients and struggling with access to enough critical care physicians, nurses, respiratory therapists, and other specialized clinical experts. Teams of critical care clinicians are available to deliver virtual care through telemedicine platforms, such as an app on a mobile device. Hear from participating clinicians, and email to learn more and sign up.
Mobilizing Health Care Workforce via Telehealth. ProviderBridge.org was created by the Federation of State Medical Boards through the CARES Act and the FORHP-supported Licensure Portability Grant Program. The site provides up-to-date information on emergency regulation and licensing by state as well as a provider portal to connect volunteer health care professionals to state agencies and health care entities.
New: Reaching Farm Communities for Vaccine Confidence. The AgriSafe Network is a nonprofit organization that provides information and training on injury and disease related to agriculture. Their health professionals and educators created a social media toolkit that aims to provide clear messages about COVID-19 vaccination for agriculture, forestry, and fishing workers.
Funding and Opportunities
SAMHSA Grants for Rural Emergency Medical Services Training – February 14. The Substance Abuse and Mental Health Services Administration (SAMHSA) will make 27 awards of up to $200,000 each to recruit and train emergency medical services (EMS) personnel with a focus on mental and substance use disorders. Eligible applicants are rural EMS agencies operated by a local or tribal government and non-profit EMS agencies.
Policy Updates
Send questions to ruralpolicy@hrsa.gov.
Medicare Rule Adds 1,000 Physician Residency Slots and Other GME Policies. Last week, the Centers for Medicare & Medicaid Services (CMS) finalized several graduate medical education (GME) proposals that will enhance the health care workforce and fund additional medical residency positions in hospitals serving rural and underserved communities. This Fiscal Year 2022 Medicare Inpatient Hospital Payment Final Rule adds 1,000 new Medicare-funded residency positions prioritizing hospitals that serve areas with the greatest needs. It also allows new opportunities for rural teaching hospitals participating in an accredited rural training track to increase their full time equivalent (FTE) caps. The rule also allows hospitals beginning a new medical residency training program to reset their FTE caps and per-resident amounts under qualifying circumstances. Rural hospitals seeking a cap reset must start new residency training programs by December 2025. Finally, CMS seeks comments on alternative methods to prioritize additional FTE resident cap slots and the review process to determine eligibility for per resident amounts or FTE cap resets in specified situations.
CMS Suspends Enforcement of Vaccine Mandate While Court Ordered Injunctions Remain in Effect (pdf). This month, CMS issued a memo to State Survey Agency Directors indicating that the agency will not enforce the new rule stipulating vaccination for health care workers in certified Medicare/Medicaid providers and suppliers (including nursing facilities, hospitals, dialysis facilities and all other provider types covered by the rule). Health care facilities may voluntarily choose to comply with the Interim Final Rule at this time.
Learning Events and Technical Assistance
Assistance for Rural Public Health Workforce Funding Applications – Wednesday, January 5 at 1:00 pm ET. FORHP will hold a one-hour webinar via Zoom for those applying for the Rural Public Health Workforce Training Network Program. Applications are due March 18th for the grant that will invest $48 million to place newly trained public health professionals in rural areas. To dial in: 1-833-568-8864; Participant Code: 86083981. Contact RPHWTNP@hrsa.gov for more information or a recording of the webinar.
Resource of the Week
Federally Qualified Health Centers and the Health Center Program. This recently updated topic guide at the Rural Health Information Hub includes new FAQs on Medicare reimbursement for telehealth services, insight on financial and operational performances of health centers, and the differences between a Federally Qualified Health Center and a Rural Health Clinic.
Approaching Deadlines
Last Day for RHCs to Spend COVID-19 Testing Funds – December 31
Department of Labor Stand Down Grants for Veterans Services – December 31
USDA Guaranteed Loans for Rural Rental Housing – December 31
COVID-19 Extension for Medicare Graduate Medical Education (GME) Affiliation Agreement – January 1
Treasury Department New Markets Tax Credit Program – January 3
CDC Grants for New Investigators/Research for Interpersonal Violence Impacting Children/Youth – January 4
HRSA Family-to-Family Health Information Centers (F2F HICs) – January 5
NIHB/CDC Building Capacity for Tribal Infection Control – January 7
Nominations Sought for Indigenous Health Equity Committee – extended to January 7
NIH Research for AI/AN End-of-Life Care – January 8
Burroughs Wellcome Fund Seed Grants for Climate Change and Health – January 10
USDA Farm to School Grants – January 10
HHS Grants for Family Planning Services – January 11
HRSA Rural Residency Planning and Development (RRPD) Program – extended to January 11
HRSA Nurse Corps Loan Repayment Program – January 13
HRSA Nurse Faculty Loan Program – January 13
HRSA Rural Communities Opioid Response Program – Implementation – January 13
SAMHSA Grants for Rural Emergency Medical Services Training – February 14
CDC Research on Telehealth Strategies for PrEP and ART – January 18
Comments Requested: DEA Regulation of Telepharmacy Practice – January 18
NIH Researching Behavioral Risk Factors for Cancer in Rural Populations – January 18
Department of Labor YouthBuild Program – January 21
CDC Centers for Agricultural Safety and Health – January 24
ACL Empowering Communities for Chronic Disease Self-Management – January 25
ACL Empowering Communities to Deliver and Sustain Falls Prevention Programs – January 25
CDC Seeking Public Input on Work-Related Stress for Health Workers – Extended to January 25
HRSA Delta Region Rural Health Workforce Training Program – January 25
CDC Cancer Prevention and Control for State, Territorial, and Tribal Organizations – January 26
HRSA Access to HIV Services for Women and Children – January 28
HRSA Rural Health Network Development Planning Program – January 28
HHS COVID-19 and Health Equity Impact Fellowship – extended to January 31
HHS Technology Challenge for Racial Equity in Postpartum Care – January 31
HRSA Centers of Excellence for Training Minorities in Health Professions – January 31
SAMHSA-American Psychiatric Association Diversity Leadership Fellowship – January 31
HRSA Leadership Education in Adolescent Health – February 1
Indian Health Service Forensic Healthcare Services for Domestic Violence Prevention – February 2
Indian Health Service Substance Abuse and Suicide Prevention Program – February 2
Indian Health Service Zero Suicide Initiative – February 2
National Health Service Corps Loan Repayment Programs – Extended to February 3
CDC Research to Prevent Firearm-Related Violence and Injuries – February 4
RWJF Summer Health Professions Education Program for Underrepresented Minorities – February 5
HRSA Predoctoral Training in Public Health Dentistry and Dental Hygiene – February 7
SAMHSA Harm Reduction Program – February 7
VA Supportive Services for Veteran Families – February 7
USDA Farm and Food Worker Relief Grants – February 8
IHS Tribal Self-Governance Negotiation – February 10
IHS Tribal Self-Governance Planning – February 10
CDC Strengthening Infection Prevention – February 11
CDC Evaluating Substance Use Prevention Incorporating ACEs Prevention – February 22
HRSA Mobile Health Training – Nurse Education, Practice, Quality and Retention – February 22
USDA Rural eConnectivity Broadband Loan and Grant Program – February 22
Rural Communities Opioid Response Program-Behavioral Health Care Technical Assistance (RCORP-BHCTA) – March 9
HRSA Rural Public Health Workforce Training Network Program – March 18
HRSA Small Health Care Provider Quality Improvement Program – March 21
FCC/USAC Rural Health Care Connect Fund – April 1
FCC/USAC Telecommunications Program – April 1
USDA Local Food Purchase Assistance Program – April 5
Ongoing Opportunities
HHS/DoD National Emergency Tele-Critical Care Network
Extended Public Comment Period for FCC’s COVID-19 Telehealth Program
FCC Emergency Broadband for Individuals and Households
FEMA COVID-19 Funeral Assistance
HRSA Payment Program for Buprenorphine-Trained Clinicians – Until Funds Run Out
AgriSafe Nurse Scholar Program – March 2022
AHRQ Health Services Research Demonstration and Dissemination Grants – September 2022
AHRQ Research to Improve Patient Transitions through HIT – December 2022
American Indian Public Health Resource Center Technical Assistance
ASA Rural Access to Anesthesia Care Scholarship
Burroughs Wellcome Fund Seed Grants for Climate Change and Health – Quarterly through August 2023
CDC Direct Assistance to State, Tribal, Local, and Territorial Health Agencies
CDC Training Pediatric Medical Providers to Recognize ACEs
Delta Region Community Health Systems Development Program
Department of Commerce American Rescue Plan Funding for Indigenous Communities – September 2022
Department of Commerce: Economic Development Assistance Programs
Department of Labor Dislocated Worker Grants
DRA Technical Assistance for Delta Region Community Health Systems Development
EPA Drinking Water State Revolving Fund
FEMA/SAMHSA Crisis Counseling Assistance and Training Program (CCP)
GPHC & RWJF: Rapid Cycle Research and Evaluation Grants for Cross-Sector Alignment
HRSA Technical Assistance for Look-Alike Initial Designation for the Health Center Program
Housing Assistance Council: Housing Loans for Low-Income Rural Communities
HUD Hospital Mortgage Insurance Program
IHS Tribal Forensic Healthcare Training
IHS/DOD Medical Supplies and Equipment for Tribes (Project TRANSAM)
NARHC Certified Rural Health Clinic Professional Course
NIH Project Talk Initiative Host Site Applications
NIH Dissemination and Implementation Research in Health – May 2022
NIH Practice-Based Research for Primary Care Suicide Prevention – June 2022
NIH Research – Alcohol and Other Substance Use – Various Dates Through August 2022
NIH Research: Intervening with Cancer Caregivers to Improve Patient Outcomes – September 8, 2022
NIH Research on Minority Health/Health Disparities – September 8, 2022
NIH Research on Palliative Care in Home/Community Settings – September 8, 2022
NIH Intervention Research to Improve Native American Health – Various Dates Until September 2023
NIH Researching the Role of Work in Health Disparities – Various Dates Until September 2024
NIH Special Interest Research – Pandemic Impact on Vulnerable Children and Youth – May 2024
Nominations for National Advisory Committee on Migrant Health
Primary Care Development Corporation Community Investment Loans
Rural Graduate Medical Education Planning and Development
RWJF Investigator-Initiated Research to Build a Culture of Health
RWJF Pioneering Ideas Brief Proposals
SBA Guaranteed Loans for Small Business
Southeast Rural Community Assistance Loans
USDA Community Facilities Program
USDA Community Food Projects Technical Assistance
USDA Drinking Water and Waste Disposal for Rural and Native Alaskan Villages
USDA Economic Impact Initiative Grants
USDA Emergency Community Water Assistance Grants
USDA Healthy Food Financing Initiative Technical Assistance
USDA Intermediary Relending Program
USDA Rural Business Development Grants
USDA Rural Business Investment Program
USDA Rural Energy Savings Program
USDA Technical Assistance for Healthy Food Financing Initiative
USDA Telecommunications Infrastructure Loans
USDA Funding for Rural Water and Waste Disposal Projects
USDOT Rural Opportunities to Use Transportation for Economic Success (R.O.U.T.E.S)
The Announcements from the Federal Office of Rural Health Policy are distributed weekly. To receive these updates, send an email with “Subscribe” in the subject line.
EMS360: Fatigue Risk Management in EMS Webtool Demo
Fatigue Risk Management in EMS: Project Summary and Webtool Demo
Congress Passes Sequestration Cut Delay Bill
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TODAY | CCIIO Open Door Forum No Surprises Act
Centers for Medicare & Medicaid Services Center for Consumer Information and Insurance Oversight
Special Open Door Forum: Provider Requirements under the No Surprises Act
Wednesday December 8, 2021 | 2:00-3:00 pm Eastern Time
Conference Call Only
Participant Dial-In Number: 1-888-455-1397
Conference ID #: 8604468
The Center for Consumer Information and Insurance Oversight (CCIIO) and the CMS Office of Communication will host an orientation to provider requirements under the No Surprises Act.
Starting January 1, 2022, consumers will have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network
On July 1, 2021, the “Requirements Related to Surprise Billing; Part I,” interim final rule was issued to restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.
On September 30, 2021, a second interim final rule was issued and is open for public comment. The “Requirements Related to Surprise Billing; Part II” rule provides additional protections against surprise medical bills, including:
- Establishing an independent dispute resolution process to determine out-of-network payment amounts between providers (including air ambulance providers) or facilities and health plans.
- Requiring good-faith estimates of medical items or services for uninsured (or self-paying) individuals.
- Establishing a patient-provider dispute resolution process for uninsured (or self-paying) individuals to determine payment amounts due to a provider or facility under certain circumstances.
- Providing a way to appeal certain health plan decisions.
Together, these lay the groundwork to provide consumers with protection against surprise billing, starting in 2022. Learn more about how these rules help consumers.
Here is the link to our No Surprises page that has the slides: https://www.cms.gov/
We look forward to your participation.
Special Open Door Participation Instructions:
Participant Dial-In Number: 1-888-455-1397
Conference ID #: 8604468
Note: TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.
A transcript and audio recording of this Special ODF will be posted to the Podcast and Transcripts website at https://www.cms.gov/
For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions please visit our website at http://www.cms.gov/
Thank you for your interest in CMS Open Door Forums.
CMS | Ambulance Open Door Forum Dec 9
The next CMS Ambulance Open Door Forum scheduled for:
Date: Thursday, December 9, 2021
Start Time: 2:00pm-3:00pm PM Eastern Time (ET);
Please dial-in at least 15 minutes before call start time.
To participate by phone:
Dial: 1-888-455-1397 & Reference Conference Passcode: 8604468
Conference Leaders: Jill Darling, Maria Durham
**This Agenda is Subject to Change**
- Opening Remarks
Chair- Maria Durham, Director, Division of Data Analysis and Market Based Pricing
Moderator – Jill Darling (Office of Communications)
Announcements & Updates
- Emergency Triage, Treat, and Transport (ET3) Model Update
- ET3 Model Website: https://innovation.cms.gov/
innovation-models/et3 - ET3Model@cms.hhs.gov for inquiries
- ET3 Model Listserv for Model updates: https://public.govdelivery.
com/accounts/USCMS/subscriber/ new?topic_id=USCMS_12521
- ET3 Model Website: https://innovation.cms.gov/
- Upcoming Implementation Dates of the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model
- Ground Ambulance & Patient Billing Advisory Committee Member Nomination Period
- Submission Instructions are contained in this Federal Register Notice: https://www.federalregister.
gov/documents/2021/11/23/2021- 25560/ground-ambulance-and- patient-billing-advisory- committee
- Submission Instructions are contained in this Federal Register Notice: https://www.federalregister.
- CY 2022 Ambulance Inflation Factor (AIF) Change Request 12488, Transmittal 11044
- Medicare Ground Ambulance Data Collection System CY 2022 Physician Fee Schedule Final Rule
- Slide presentation will be available at: https://www.cms.gov/Center/
Provider-Type/Ambulances- Services-Center, under Spotlights, Upcoming Events.
- Slide presentation will be available at: https://www.cms.gov/Center/
III. Open Q&A
**DATE IS SUBJECT TO CHANGE**
Next Ambulance Open Door Forum: TBA
ODF email: AMBULANCEODF@cms.hhs.gov
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This Open Door Forum is open to everyone, but if you are a member of the Press, you may listen in but please refrain from asking questions during the Q & A portion of the call. If you have inquiries, please contact CMS at Press@cms.hhs.gov. Thank you.
Open Door Participation Instructions:
This call will be Conference Call Only.
To participate by phone:
Dial: 1-888-455-1397 & Reference Conference Passcode: 8604468
Persons participating by phone do not need to RSVP. TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.
Instant Replay: 1-800-856-2271; Conference Passcode: No Passcode needed
Instant Replay is an audio recording of this call that can be accessed by dialing 1-800-856-2271 and entering the Conference Passcode beginning 1 hours after the call has ended. The recording is available until December 11, 2021, 11:59PM ET.
For ODF schedule updates and E-Mailing List registration, visit our website at http://www.cms.gov/
Were you unable to attend the recent Ambulance ODF call? We encourage you to visit our CMS Podcasts and Transcript webpage where you can listen and view the most recent Ambulance ODF call. Please allow up to three weeks to get both the audio and transcript posted to: https://www.cms.gov/Outreach-
CMS provides free auxiliary aids and services including information in accessible formats. Click here for more information. This will point partners to our CMS.gov version of the “Accessibility & Nondiscrimination notice” page. Thank you.
CCIIO Open Door Forum No Surprises Act
From CMS on December 3, 2021
Centers for Medicare & Medicaid Services Center for Consumer Information and Insurance Oversight
Special Open Door Forum: Provider Requirements under the No Surprises Act
Wednesday December 8, 2021 | 2:00-3:00 pm Eastern Time
Conference Call Only
Participant Dial-In Number: 1-888-455-1397
Conference ID #: 8604468
The Center for Consumer Information and Insurance Oversight (CCIIO) and the CMS Office of Communication will host an orientation to provider requirements under the No Surprises Act.
Starting January 1, 2022, consumers will have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network
On July 1, 2021, the “Requirements Related to Surprise Billing; Part I,” interim final rule was issued to restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.
On September 30, 2021, a second interim final rule was issued and is open for public comment. The “Requirements Related to Surprise Billing; Part II” rule provides additional protections against surprise medical bills, including:
- Establishing an independent dispute resolution process to determine out-of-network payment amounts between providers (including air ambulance providers) or facilities and health plans.
- Requiring good-faith estimates of medical items or services for uninsured (or self-paying) individuals.
- Establishing a patient-provider dispute resolution process for uninsured (or self-paying) individuals to determine payment amounts due to a provider or facility under certain circumstances.
- Providing a way to appeal certain health plan decisions.
Together, these lay the groundwork to provide consumers with protection against surprise billing, starting in 2022. Learn more about how these rules help consumers.
Here is the link to our No Surprises page that has the slides: https://www.cms.gov/
We look forward to your participation.
Special Open Door Participation Instructions:
Participant Dial-In Number: 1-888-455-1397
Conference ID #: 8604468
Note: TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.
A transcript and audio recording of this Special ODF will be posted to the Podcast and Transcripts website at https://www.cms.gov/
For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions please visit our website at http://www.cms.gov/
Thank you for your interest in CMS Open Door Forums.
Call to Action: Write Your Members of Congress Today!
Our nation’s EMS infrastructure is at risk. Ground ambulance service organizations are facing a financial crisis due to the lack of adequate reimbursement for their services and a crippling shortage of paramedics and EMTs. If Congress does not act soon, the situation will become worse with an additional 4% sequestration cut for all Medicare providers and suppliers including for ground ambulance services. Our nation’s 9-1-1 EMS infrastructure is at risk.
Place follow the link below to contact your members of Congress and ask that they protect ground emergency and non-emergency ambulance services in our communities.
EMS1 | 2021 EMS Trend Report
The 2021 EMS Trend Report, produced in collaboration with Fitch & Associates and the National EMS Management Association, and sponsored by Pulsara, continues our effort to identify how those in EMS perceive growth, change and the challenges impacting the sustainability and future of the industry.
Last year, we said that 2020 would be a “defining year” for EMS. Even at the time, soon after the emergence of the new coronavirus in the U.S., we didn’t realize how much that might be true. It certainly was a defining year for EMS, for healthcare and for the entire global community.
A year later, the long-term impacts of the pandemic on our profession remain uncertain. What we do know is how the pandemic highlighted the adaptability of EMS. The sixth annual EMS Trend Report dives into the impact COVID-19 had, and didn’t have, the changes we’re embracing and the change providers want to see, as we explore the opinions, concerns and hopes of your colleagues across EMS at this critical moment in history.
Download your copy to read:
- The state of the profession: The more things change, the more they stay the same
- Roundtable: Incremental change through transformative events
- Is poor leadership more dangerous than a pandemic?
- Why EMS systems that scale represent the future of EMS
- 8 Places to invest in provider safety
CMS | Data Collection Q&A December 14
From CMS
Medicare Ground Ambulance Data Collection System Webinar: Question and Answer (Q&A) Session Tuesday, December 14, 2021 | 2:00 PM – 3:00 PM ET
To register for this CMS Zoom webinar:
https://cms.zoomgov.com/webinar/register/WN_Jy_wpLZLQnuNu5vv_5Dbyw
After registering, you will receive a confirmation email containing information about joining the webinar.
Do you have questions about the Medicare Ground Ambulance Data Collection System? We are holding a live Q&A session on December 14, 2021 at 2:00 pm. Please send questions in advance to AmbulanceDataCollection@cms.hhs.gov with “December 14 Q&A” in the subject line. We will answer your questions that you submitted in advance during the call or participants may also submit live questions using the “Q&A” button at the bottom of your Zoom screen. In addition, we will update documents on our Ambulances Services Center webpage with answers to common questions from this session.
For more information, including the list of ground ambulance organizations selected to collect and report information starting in 2022, see the Ambulances Services Center webpage, the CY 2022 PFS Final Rule, the CY 2020 PFS final rule, and the Bipartisan Budget Act of 2018.
NHTSA Publishes New National EMS Education Standards
Revised Standards outline minimum competencies for entry-level EMS clinicians to perform their roles
After a community-wide, collaborative effort, the newly updated National EMS Education Standards are now available. The Standards outline the critical topics to be covered in the initial education of EMS clinicians, based on the latest version of the National EMS Scope of Practice Model as well as recent research and best practices. The document defines the competencies, clinical behaviors, and judgments required of EMS personnel to perform their roles. They provide a high-level outline of those topics, and do not replace the need to develop a curriculum, nor are they intended to limit EMS educational programs from going beyond the Standards to meet student or community needs.
The National EMS Education Standards were first published in 2009, and this marks the first major revision. The National Highway Traffic Safety Administration (NHTSA) and the Health Resources and Services Administration, Maternal and Child Health Bureau’s EMS for Children Program funded the effort through a process led by the National Association of EMS Educators.
“EMS clinicians are the most critical resource in our nation’s EMS systems, and education is the foundation upon which those clinicians are created,” said Dr. Jon Krohmer, director of the NHTSA Office of EMS. “These newly released National EMS Education Standards, created by the EMS community, will help educators and education content providers continue to create competent, compassionate clinicians dedicated to providing people-centered, evidence-based care to their communities.”
Visit EMS.gov to learn more about the revised 2021 National EMS Education Standards, download the Standards themselves, and find frequently asked questions about the project.