Memo-12-12-2017-Item-12

December 12, 2017 - View PDF of EMS Transition Report

MEMO TO:        Mayor Barber and Board of Commissioners

FROM:             Frank A. Rush, Jr., Town Manager

SUBJECT:       EMS Transition - (Summary & Suggested Motions) (EMS Key Points)

The Board of Commissioners is scheduled to receive an update on the transition of Emerald Isle EMS to a Town department at the December 12 meeting.  Based on the Board of Commissioners’ previous decision in April 2017, Town staff have been working to implement a March 1, 2018 transition date, which is now less than 3 months away.  With continued diligence and cooperation between the Town and EI EMS, Inc., I am confident that we can meet this self-imposed deadline and implement a new Town EMS Department this coming spring.

As you know, the EMS transition has been contemplated by the Town and Emerald Isle EMS, Inc. for more than a decade.  The Board of Commissioners has discussed this issue and has considered the various service models numerous times over the years.  In order to provide background and context for the Board of Commissioners and the public, I have also included a review of the history and current emergency medical services in Emerald Isle, a discussion of EMS service models used in other jurisdictions in North Carolina and Carteret County, a discussion of other EMS service models that have been considered over the years and that remain available for the Board of Commissioners to consider if desired now or in the future, and a review of the Board of Commissioners’ previously determined rationale for proceeding with the transition to a Town EMS Department. 

I will make a brief presentation to the Board of Commissioners and the public about these issues at the December 12 meeting, and will be available to answer any questions from the Board of Commissioners.  I have also invited other EMS experts to attend the meeting to share any insights and answer any questions from the Board of Commissioners, including Chuck Lewis -  Assistant Chief of the NC Office of Emergency Medical Services, Stephen Rea – Carteret County Emergency Services Director, and Dr. Michael Lowry – Carteret County EMS Medical Director.

Emergency Medical Services in Emerald Isle

Emergency medical services in Emerald Isle are primarily provided by Emerald Isle, EMS, Inc. (EIEMS, Inc.), a separate non-profit corporation that is contracted by the Town of Emerald Isle.  The Town of Emerald Isle, as delegated by Carteret County, is the official entity responsible for the provision of emergency medical services in our community, and may choose from any legal service model to provide these services for our residents and visitors.

Prior to 2001, EIEMS, Inc. functioned as a completely volunteer organization supported by fundraising initiatives, and did not receive any tax funding or service fee revenue.  EIEMS, Inc. was “built” by the hard work, dedication, and commitment of numerous Emerald Isle volunteers in the 1970s, 80s and 1990s, and for many years the volunteer squad operated out of a converted beach house on Cedar Street (since renovated and converted back to residential use; located directly behind Shorewood Real Estate offices).  

By 2001, consistent with regional and national trends, EIEMS, Inc. began to experience a decline in volunteerism and it became more difficult to provide these services exclusively with volunteers and fundraising initiatives.  In 2001, the Town and EIEMS, Inc. implemented the first formal contract for emergency medical services, and the Town provided $100,000 of tax funding to support EIEMS, Inc.  As service demands continued to increase, volunteerism continued to decline, and as many of the original volunteers moved on, there became a greater need for paid staff and additional Town funding.  In response to these needs, the Town and EIEMS, Inc. executed several contract extensions and new contracts between 2001 and 2017, and EIEMS, Inc. now operates with a fully-paid staff of paramedics and emergency medical technicians overseen by a non-profit, volunteer Board of Directors.  Until April 2017, the entire EIEMS, Inc. Board of Directors was selected by the volunteer members of the squad, however, a new contract provision stipulates that the Board of Directors include 3 members selected by the volunteer members of the squad and 2 members appointed by the Board of Commissioners.    

Prior to contracting with the Town, EIEMS, Inc.’s primary funding source was an annual donation letter campaign to all Emerald Isle property owners.  EIEIMS, Inc. completely abandoned this approach in the early 2000s when the Town began providing annual funding to EIEMS, Inc., and this approach was not utilized for more than a decade until 2016 and 2017 when EIEMS, Inc. solicited donations specifically to fund desired capital equipment.  As you know, there has been some concern about the re-initiation of the donation letter campaign in light of the fact that the Town has provided significant tax funding to EIEMS, Inc. since 2001.  

The amount of Town funding has steadily increased between 2001 and 2017, and Town and EIEMS, Inc. officials have worked cooperatively to provide the highest level of service in the most cost-effective manner over the years.  By FY 2008-09, the Town’s annual tax funding provided to EIEMS, Inc. had increased to approximately $327,000.  In 2008, in response to continuing demands for additional paid personnel and other growing expenses, EIEMS, Inc. implemented new service fees to supplement the Town’s annual funding.  Approximately $129,000 of service fees were realized in FY 2008-09, and these funds have continued to grow each year since and have been critical in enabling the Town and EIEMS, Inc. to meet service demands since that time.  By FY 2016-17, the Town’s annual tax funding provided to EIEMS, Inc. had increased to $390,000, and was supplemented by nearly $204,000 of service fee revenues.  Thus, the total amount of public funding provided to EIEMS, Inc. in FY 2016-17 was nearly $600,000.  A graph indicating the annual Town funding and EMS service fee revenues is attached for your information.  The Board of Commissioners should note that these amounts do not include any additional fundraising proceeds generated by EIEMS, Inc. (pancake breakfasts, donations, and other fundraising activities), and that these fundraising proceeds have been used solely at the discretion of the EIEMS, Inc. Board of Directors with no Town involvement.

As noted, EIEMS, Inc. has evolved from a completely volunteer-staffed organization in 2001 to a fully-paid staff.  By 2007, the EIEMS, Inc. budget included approximately $125,000 for part-time personnel.  In 2008, full-time staff was added for the first time, and the total budget for full-time and part-time staff had increased to approximately $197,000.  Additional full-time and part-time staff have been added over the past decade, and the total EIEMS, Inc. budget for FY 2017-18 includes approximately $415,000 in full-time and part-time staff expenses.  EIEMS, Inc. is now staffed by 7 full-time employees (Chief, 3 Paramedics, and 3 Emergency Medical Technicians), and also relies on as many as 17 part-time staff to cover additional shifts.  EIEMS, Inc. operates with one paid Paramedic and one paid Emergency Medical Technician (EMT) on duty at all times at the Town-owned EMS Station, and during busy summer weekends a second 2-person crew is on duty due to higher call volumes.  Emerald Isle Fire Department personnel, also trained as emergency medical technicians, supplement EIEMS, Inc.’s response, and serve as “first responders”.  EIEMS, Inc.’s response is also supplemented by a small group of dedicated volunteers, and there are a total of 7 volunteers who have responded to 40 or more calls in the past year.  There are an additional 10 volunteers who have responded to a handful of calls (generally less than 10 each) in the past year.  (The Board of Commissioners should note that some of these volunteer calls are to the same incident, with multiple volunteers responding to the same call.)

As Emerald Isle has increased in popularity over the years, and as more people spend more time in Emerald Isle, the workload for EIEMS, Inc. has increased significantly.  In FY 2000-01, EIEMS, Inc. responded to 464 calls for service, and this number increased to 945 calls for service by FY 2016-17.  The Emerald Isle Fire Department provided “first responder” assistance on 604 calls during FY 2016-17.   

EIEMS, Inc. has operated out of the Town-owned EMS station (on the Town government complex) since it opened in 2008.  The new station replaced the previous converted beach house on Cedar Street, and this project was initiated by the Town to provide a quality facility in Emerald Isle for these services and EMS personnel.  The new station represented the significant spirit of cooperation that has existed between the Town and EIEMS, Inc. since 2001, and included a total investment of approximately $1 million by the people of Emerald Isle (funded by a combination of Town tax revenues, accumulated donations and fundraising proceeds, sale proceeds of the old Cedar Street beach house, and on Town-owned land).

EIEMS, Inc. operates with two fully-equipped ambulances, one quick-response truck, and an all-terrain vehicle.  EIEMS, Inc. also utilizes significant additional equipment, including defibrillators, electric-lift stretchers, and other equipment that is required on all ambulances in North Carolina.

Since 2001, EI EMS, Inc. has utilized approximately $6.1 million of public funding (approximately $4.6 million of tax funding and approximately $1.5 million of service fee revenues) to provide emergency medical services in Emerald Isle.  This amount does not include the public funding for the EMS station.  The reality is that EI EMS, Inc. would not have continued to operate for the past decade+ without the support of and partnership with the Town of Emerald Isle.  EIEMS, Inc. specifically sought Town funding in 2001 because their fundraising efforts could no longer generate the necessary funds to provide quality emergency medical services in Emerald Isle.  

Emergency Medical Services in North Carolina

In North Carolina, emergency medical services are typically provided and financed by County governments, although municipalities are also authorized under NC law to provide emergency medical services. 

In many NC counties, services are provided by a County-wide EMS department providing consistent services across the entire County jurisdiction at the paramedic level of care (for example, Onslow County operates under this model).  Under this model, County EMS employees respond in County-owned ambulances.  In a handful of NC counties, EMS services are provided by EMS departments operated through a regional or local hospital system, under an agreement with the County government (New Hanover County utilizes this model).  In some counties, EMS services are provided by a combination of County EMS employees and multiple agreements with non-profit emergency medical services squads and municipalities serving specific sub-areas of the County (Carteret County utilizes this model), and the standard of care may not be consistent across the entire County jurisdiction. 

As volunteerism has declined in our society over the past few decades, as service demands have increased, and as training and certification requirements have increased, there has been a continual shift away from volunteer-provided emergency medical services to fully-paid, professional staff providing these services, and most jurisdictions in North Carolina are now served by fully-paid, professional staff.  It is not uncommon for very rural communities in North Carolina to be served by paid, professional staff, and I am not aware of any cities and towns of comparable size to Emerald Isle that are not served by fully paid, professional staff. 

Additionally, there are very few municipalities in North Carolina that contract directly with a non-profit EMS provider to serve only their jurisdiction – utilizing a model similar to that used in Emerald Isle.  In nearly all municipalities in North Carolina (there are more than 540 cities and towns in North Carolina), emergency medical services are provided by either a County-wide EMS system, a municipal Fire & EMS department, a hospital-based emergency medical services provider, or the County government contracts with a non-profit emergency medical services provider.  Additionally, I am not aware of any municipal EMS-only departments operating in North Carolina, and Emerald Isle may be one of only a few municipalities utilizing this model when the transition is completed on March 1, 2018. 

Chuck Lewis, Assistant Chief of the NC Office of Emergency Medical Services, can share additional perspective on the various service models used in North Carolina. 

Understanding the Services Provided by EMS Departments vs. the Services Provided by Fire Departments

The highest standard of care in emergency medical services is the “paramedic” level of care, with specific and rigorous training and certification requirements.  In many NC municipalities, the County government is the primary provider of emergency medical services (at the paramedic level of care) to the residents of the entire County (including the municipalities).  Often, the municipal Fire Department then provides supplemental “first-responder” services with trained emergency medical technicians at the “basic” or “intermediate” level of care (which involves fewer training and certification requirements).  Under this service model, these municipal Fire departments are not the primary care providers, and trained Fire personnel (operating at the basic or intermediate level of care) supplement the capabilities of the primary EMS provider (operating at the paramedic level of care). 

This Fire Department “first responder” model is used in Emerald Isle, and in many other NC counties and municipalities – it is fairly typical for city or town Fire Departments to provide first responder services regardless of the EMS service model utilized.  However, Carteret County is somewhat unique in North Carolina in that there are several combined Fire & EMS departments operating in Carteret County with personnel trained as both paramedics and firefighters, providing both emergency medical services and fire services.  For example, the towns of Atlantic Beach, Morehead City, Pine Knoll Shores, and Indian Beach all provide (or will soon provide) paramedic level services in their municipal jurisdiction with a combined Fire & EMS department.

Emergency Medical Services in Carteret County

Carteret County operates a very fragmented system of emergency medical services, with a total of 14 different and autonomous EMS service providers.  There have been several reports commissioned by the Carteret County Commissioners in the past few decades to explore the possibility of implementing a County-wide EMS system, however, due to political complexities these efforts have not resulted in any significant changes in the EMS service model in Carteret County.  Over the past decade, Carteret County has added paid paramedics that provide roving services in quick-response vehicles positioned in strategic areas of the county to provide additional services, and these paramedics are funded by the County’s General Fund budget.   

In Carteret County, the towns of Atlantic Beach and Pine Knoll Shores operate municipal Fire & EMS departments that are funded by Town tax revenues and service fees, and provide services only in their municipal jurisdictions.  In the towns of Morehead City, Newport, and Indian Beach, municipal Fire & EMS departments are funded by Town tax revenues, service fees, and also by County special district taxes because they also serve limited areas outside of their municipal limits.  In the towns of Cedar Point, Cape Carteret, Bogue, and Peletier, and in nearby unincorporated areas, Fire & EMS services are provided by the Western Carteret Fire & EMS Department that is funded by County special district taxes, overseen by a special Board of Directors that includes elected officials from each town and others, and that has special municipal status because it serves 4 different municipalities in partnership with one another.  Carteret County contracts with a non-profit service provider that provides services in the Beaufort municipal limits and also in unincorporated areas outside of Beaufort, and is funded by County special district taxes established by the County Commissioners.  In all other unincorporated areas of Carteret County, the county contracts with non-profit service providers that are funded by County special district taxes established by the County Commissioners.  I have attached a map (from 2014) produced by Carteret County that identifies all of the EMS providers in Carteret County and their coverage areas.  

Carteret County is served by a County Emergency Services Director (Stephen Rea) who oversees the County’s paid paramedics (roving in quick-response vehicles) and the various contracts between the County and the various service providers.  Additionally, the Carteret County Commissioners appoint the Carteret County Fire & EMS Commission that reviews the various budget requests from the service providers funded by County special district taxes and advises the County Commissioners on Fire and EMS issues.  All EMS units in Carteret County (including Emerald Isle) operate under the license of and according to protocols established by the Carteret County EMS Medical Director, Dr. Michael Lowry.     

Stephen Rea and Dr. Michael Lowry can share additional perspective on the various emergency medical service providers utilized in Carteret County.   

Historical Evolution Leading to Board of Commissioners’ April 2017 Decision to Transition to Town EMS Department - (EMS Items 2007-2017) (Current EMS Agreements)

The Town and EIEMS, Inc. have been very fortunate to enjoy a positive and cooperative relationship since 2001, and have worked together to insure that quality emergency medical services have been and remain available to the residents and visitors of Emerald Isle.  As noted earlier, however, the relationship between the Town and EIEMS, Inc. has evolved significantly over the past two decades as the Emerald Isle community has grown, volunteerism has declined, and service demands have increased, and the planned March 1, 2018 transition represents another step in the evolution of emergency medical services in Emerald Isle.

There have been many changes over the years that have led the Town, as the entity ultimately responsible for the provision of emergency medical services in Emerald Isle, to this point.  In short, everyone involved with emergency medical services in Emerald Isle since 2001 (from both the Town and EIEMS, Inc.) has acknowledged that EIEMS, Inc. would eventually become a part of the Town government organization at some point in the future – that it was just a matter of when.  All involved knew that eventually the service demands would increase, the complexities of EMS would continue to grow, the EMS organization would become larger, and that the public expense would continue to increase.  In recognition of this ultimate reality, since 2005 the Town’s contracts with EIEMS, Inc. have stipulated the need for both parties to work cooperatively to determine the best long-term strategy for emergency medical services in Emerald Isle.  Beginning in 2010, more specific plans and discussion have occurred annually, with a stated preference (by all involved) for the eventual creation of a Town EMS Department. 

In addition to the continued increase in part-time staff, full-time staff, and total EMS expenses since 2001, the following events have occurred over the years that have led to this point:

  • March 2005 – a new 5-year contract between the Town and EIEMS, Inc. is executed, and includes the creation of the Joint EMS Committee and stipulates the need to determine the best long-term strategy for emergency medical services in Emerald Isle,
  • September 2007 – the Town and EIEMS, Inc. partner together to construct a new, modern EMS station on Town-owned land in an effort to improve facilities and also guarantee the perpetual location of an EMS station in Emerald Isle amid additional discussion about a new County-wide EMS system (the new station opened in September 2008); this initiative is the best example of the great strength of this partnership in the past,
  • April 2010 – a new 1-year contract extension is executed, with very specific direction to the Joint EMS Committee to determine the best long-term strategy for emergency medical services in Emerald Isle,
  • November 2010 – a draft framework (copy attached) for a new Town EMS department is reviewed by Joint EMS Committee, with support for transition growing,
  • May 2011 – after considering the transition to a Town EMS department, the Joint EMS Committee ultimately recommends and the Board of Commissioners executes a new 1-year contract extension, however, as part of continued efforts toward the eventual transition to the Town government, a new contract results in the Town providing all financial administration and payroll administration services for EIEMS, Inc.,
  • Each year, 2012 – 2016 – additional discussion by Joint EMS Committee and the Board of Commissioners during annual budget deliberations about the eventual transition of EMS to the Town government organization,
  • November 2016 – April 2017 – there are inconsistent approaches and statements by EIEMS, Inc. regarding the need for (or lack of need for) a full-time EMS Chief position, the dismissal of the previous Chief, and rapid attempts to name a new Chief shortly after the dismissal of the previous Chief,
  • January 2017 – April 2017 – significant internal controversy in EIEMS, Inc. during this time, and concerns about the effective management of the EMS organization, the significant (now nearly $600,000 annually) annual public expense, and the gradual evolution of EMS in Emerald Isle such that the eventual transition to a department of the Town government is now warranted,
  • February, March 2017 – an updated framework (copy attached) for a new Town EMS department is presented to EIEMS, Inc. Board of Directors, volunteers, and staff; some long-term volunteers express their support for the Town transitioning EMS to a Town department immediately,
  • April 2017 – Board of Commissioners and EIEMS, Inc. Board of Directors approve a new 10 ½ month contract extension to expire on March 1, 2018, with two Town appointees to EIEMS, Inc. Board of Directors and with a clear provision for both parties to work cooperatively and diligently toward the transition of EI EMS, Inc. to a department of the Town government as early as March 1, 2018,
  • April 2017 – Board of Commissioners states its intention for the new contract to be the last contract executed with EIEMS, Inc., with a goal to implement the transition by March 1, 2018, and directs Town staff to implement the transition,
  • April 2017 – December 2017 – Town staff initiates work to implement the EMS transition by March 1, 2018,
  • April 2017 – December 2017 – concern from the Town about certain EIEMS, Inc. management decisions, and some EIEMS, Inc. leaders also make questionable comments that suggest a lack of cooperation with the Town on the EMS transition.

In recent weeks, at least one EIEMS, Inc. leader has publicly questioned the need for the transition and/or has expressed opposition to the transition.  I believe this opposition to be limited to a small group of individuals associated with EIEMS, Inc., and recent discussion with EIEMS, Inc. full-time employees indicates their willingness and/or enthusiasm to become a part of the Town organization by March 1, 2018.  Based on the Board of Commissioners’ directive, Town staff continue to work to implement the transition and will continue to do so unless directed otherwise by the Board of Commissioners. 

Other Service Models That Have Been Considered In The Past / May Still Be Considered By the Board of Commissioners in the Future

In order to provide background and context, I have included a discussion of the other service models that have been discussed over the years, and that remain available for consideration by the Board of Commissioners now and in the future if desired. 

As noted, the most common EMS service model used in North Carolina is a County-wide EMS system managed and financed by County government.  Other service models utilized in North Carolina include a hospital-based model, a (combined) Fire & EMS department, a contract relationship between a county or municipality and a non-profit Fire and/or EMS organization, or a municipal EMS department.  Each of these service models has been discussed in the past, and a summary of each model is presented below.

County-wide EMS system managed and financed by County government 

This model has been evaluated by Carteret County several times in the past, but has never been implemented due to political complexities associated with the fact that there are 14 different EMS service providers that may be unwilling to cede control of these services. 

If, however, the Town of Emerald Isle requested that Carteret County provide these services in Emerald Isle, I believe that the County would entertain this request and (hopefully) work cooperatively to assume control of this service, as it would further future efforts toward the creation of a centralized EMS system in Carteret County, similar to many other counties in North Carolina. 

If EMS services were transferred from Emerald Isle to Carteret County, the County would finance and provide these services at the paramedic level of care operating out of the current EMS station.  The Town would realize annual budget savings of $390,000, and could reduce the Town property tax rate by approximately 1.5 cents (from 15.5 cents to 14 cents).  The disposition of the current EMS station and other EMS assets would be negotiated with Carteret County, and it is possible that these assets would simply be contributed to the County or it may be possible for the Town to negotiate the purchase or rental of these assets by the County.

In Emerald Isle, proponents of this service model might claim that:

  • this service model is the predominant model that North Carolina counties have evolved to,
  • this service model removes the Town from managing this service, and enables the Town to focus on other community priorities,
  • a clear focus solely on emergency medical services would result in better quality service, and that service providers would not be “distracted” by fire or other duties,
  • this service model promotes an economy of scale, more efficient use of expensive resources, and provides professional development opportunities for EMS personnel that will ultimately result in improved services, and
  • the assumption of this service by the County would reduce the Town’s property tax rate by 1.5 cents.

In Emerald Isle, opponents of this service model might claim that:

  • the transfer of this service from the Town to the County may result in decreased quality of service because the County staff would not be supervised by individuals with a closer connection to the Emerald Isle community,
  • the conversion of this service to a larger organization would eliminate the close-knit feel between service providers and the residents of Emerald Isle,
  • although unlikely, the County could make a future decision to move the EMS station out of Emerald Isle if it is more cost-effective for their overall service area to be based in a different location, and
  • the County may implement service strategies that result in the Emerald Isle-based crew performing more services outside of the Emerald Isle municipal limits.

Hospital-based service model

This model has never seriously been considered by the Town, although various informal discussions about such a model have occurred in Carteret County over the years, but have obviously not been pursued.  Although it is unlikely that Carteret Healthcare would consider this model, if the Board of Commissioners has interest in exploring this model, I will convene the appropriate meetings with Carteret County and Carteret Healthcare officials to explore this service model in the future.  Of all of the service model options available, this model is likely the most complex to implement.

In Emerald Isle, proponents of this service model might claim that:

  • the hospital is ideally suited to provide the most effective emergency medical services, and this service complements the hospital’s overall mission,
  • this service model removes the Town from managing this service, and enables the Town to focus on other community priorities,
  • a clear focus solely on emergency medical services would result in better quality service, and that service providers would not be “distracted” by fire or other duties,
  • this service model promotes an economy of scale, more efficient use of expensive resources, and provides professional development opportunities for EMS personnel that will ultimately result in improved services, and
  • the assumption of this service by the hospital would reduce the property tax burden for Emerald Isle property owners, and transfer the financial responsibility to the users of these services.

In Emerald Isle, opponents of this service model might claim that:

  • it is likely a much more complex process to establish a hospital-based model in Carteret County, and may not be feasible,
  • the transfer of this service from the Town to the hospital may result in decreased quality of service because the hospital staff would not be supervised by individuals with a closer connection to the Emerald Isle community,
  • the conversion of this service to a larger organization would eliminate the close-knit feel between service providers and the residents of Emerald Isle,
  • although unlikely, the hospital could make a future decision to move the EMS station out of Emerald Isle if it is more cost-effective for their overall service area to be based in a different location, and
  • the hospital may implement service strategies that result in the Emerald Isle-based crew performing more services outside of the Emerald Isle municipal limits.

(Combined) Municipal Fire & EMS department model

This model has been successfully utilized by the Town of Atlantic Beach and the Town of Morehead City for many years, and could be implemented in the Emerald Isle Fire Department if desired. 

Under this service model, the Town would hire all existing full-time EMS employees and incorporate them into the Fire Department.  Over several months, these employees would receive training and certification as basic firefighters (which is not difficult or time consuming to obtain), and would perform minimal fire duties (with their primary emphasis on emergency medical services).  If these employees are incorporated into the Emerald Isle Fire Department, the Town would increase staffing at both fire stations from 5 personnel at all times to 7 personnel at all times.  One ambulance would be permanently stationed at each of the Town’s two fire stations.  As existing EMS employees receive additional training and eventually achieve paramedic certifications, the Town would eventually be able to offer 2 paramedics on duty at all times during the year (as opposed to only on busy summer weekends under the current contract model), and could eventually station 1 paramedic at each of the Town’s two fire stations.  This model would also improve firefighter safety and compliance with national firefighting standards, and could potentially promote a better fire insurance rating. 

Under this model, an EMS Chief position would not be necessary (one paramedic could be assigned Captain or Assistant Chief status in the EI Fire Department, or perhaps the Chief of the combined department would eventually be someone with a more extensive EMS background in the future), thus only 6 full-time positions would be added.  Additionally, employees in the combined department would be subject to FLSA regulations that do not require overtime pay until an average of 53 hours per week is worked, as opposed to 40-hour regulations for EMS-only employees.  (Appropriate salary adjustments would be made for existing EIEMS, Inc. employees to insure that their compensation is not reduced by the application of FLSA regulations.)

Under this model, it is not necessary for a separate Board of Directors to manage this service, and the Board of Commissioners would serve as the “ultimate Board of Directors”, as it does for all other Town departments, including Police, Public Works, and other Town departments.

This model would result in improved communication and coordination with other Town departments, and would also result in other operational efficiencies.  The Town would continue to welcome and encourage EMS volunteers to assist in any way desired by the volunteers.  It is anticipated that EIEMS, Inc. would continue to exist as a separate organization that supplements paid staff, serves as an EMS advisory Board to the Chief, Town Manager, and Board of Commissioners, and engages in fundraising activities.  

The total annual cost associated with this model (which includes improved benefits – including better health insurance and retirement plans - for current EMS employees) is estimated at approximately $550,000.  The Board of Commissioners should note that this cost would increase to approximately $585,000 with the future achievement of paramedic status by current EMS employees.  This annual cost can be accommodated by the Town’s historical EMS funding and service fee revenues.

In Emerald Isle, proponents of this service model might claim that:

  • the integration of EMS services into the Fire Department will improve communication and coordination with other Town staff,
  • Fire Department personnel are already trained as emergency medical technicians and are responding to most EMS calls already, thus this approach is more efficient, 
  • existing EIEMS, Inc. employees would become Town employees in a combined Fire & EMS department and would receive improved employee benefits,
  • cross-training of personnel for Fire and EMS duties maximizes the Town’s efficiency and effectiveness in providing both essential services, and
  • this service model would ultimately enhance emergency medical services by staffing 2 paramedics every day of the year (instead of busy summer weekends only), and theoretically would improve EMS response time in eastern and central Emerald Isle by operating out of Fire Station 2.

In Emerald Isle, opponents of this service model might claim that:

  • the dual provision of fire services may “distract” employees from a clear focus on emergency medical services, and that EMS would not receive the proper priority from department leaders that have placed a historical emphasis on fire services,
  • EMS employees may not be interested in performing fire duties, and thus they may not find it appealing to work in Emerald Isle,
  • EMS volunteers may not be interested in serving a combined Fire & EMS department, and
  • EMS fundraising activities will decline if service is provided by a Town department.

Continued contract relationship with Emerald Isle EMS, Inc.

This model would continue the Town’s historical relationship with EIEMS, Inc., and would continue current service levels.  The Town would continue to fund EIEMS with an annual appropriation from the General Fund.  EMS employees would not be Town employees and would not receive Town benefits.  As you know, the Board of Commissioners previously stated its intent to no longer utilize this model as of March 1, 2018.

The management of EIEMS, Inc. would continue to rest with the three EMS volunteers and two Town-appointed members of the EIEMS, Inc. Board of Directors.  This model would presumably be most attractive to the three EMS volunteers who currently serve on the EIEMS, Inc. Board of Directors, as they would continue to be actively involved in the management of EI EMS, Inc., and would not cede any authority to the Town.  Because there are only a handful of EMS volunteers that are active in the organization and participate in officer elections, the three EMS volunteers serving on the EIEMS, Inc. Board of Directors are only accountable to a very small group of people, and some of these volunteers do not live in Emerald Isle.  In contrast, the Emerald Isle Board of Commissioners is accountable to the entire voting population of the Town, as they are for all other Town departments (Police, Fire, and other Town departments). 

The total EMS budget for FY 2017-18 is $575,000, however, EIEMS, Inc. added an additional full-time position in May 2017 (despite the Town’s request that the creation of this new position be delayed and considered by the Joint EMS Committee), and this new position is expected to increase the annual budget by anywhere from $15,000 - $30,000 annually (depending on whose projection is ultimately correct).  This would likely increase the amount of the annual EMS budget to $590,000 - $605,000.  These additional costs can likely be accommodated in the Town’s existing budget.

As noted, this service model is unusual.  It is rare to find a fully-paid EMS organization serving a city or town as large as Emerald Isle that operates with nearly $600,000 of public funding annually that is not a part of a county or town government.  Under this service model, approximately $600,000 of public funding annually would continue to be entrusted to the EIEMS, Inc. Board of Directors with limited accountability.   

In Emerald Isle, proponents of this service model might claim that:

  • the current service quality is high, and is likely to continue under this service model,
  • a clear focus solely on emergency medical services would result in better quality service, and that service providers would not be “distracted” by fire or other duties,
  • services will continue to be supplemented by volunteers under this model, as opposed to a claimed decrease in volunteer services under other service models,
  • EMS fundraising activities will be more effective if it is not a department of the Town government, and
  • the continuation of this service model is the least disruptive, as it maintains the status quo.

In Emerald Isle, opponents of this service model might claim that:

  • this service model is outdated for the complexity and size of Emerald Isle, and is not sustainable in the long-term,
  • the Town will continue to have limited input into the management of EMS services, while still providing significant sums of public funding, financial administration, and payroll services,  
  • there is limited accountability for EMS leaders that are selected by a small number of volunteers, some of whom are only active in a very limited capacity and some of whom do not live in Emerald Isle,  
  • this service model does not promote maximum communication and coordination with other Town departments, and
  • volunteers are welcome and encouraged to serve under the other service models, and may also engage in certain fundraising initiatives.

Municipal EMS department

As determined by the Board of Commissioners in April 2017, this model is in the process of being implemented by March 1, 2018.  This model would continue current service levels and staffing, but as a Town department.  EMS employees would become Town employees and receive Town benefits.  EMS salaries would remain at current levels, and be adjusted in the future as deemed necessary or strategic.  The EMS Chief would be selected by the Town Manager via a competitive and objective process, as is used for all Town department heads and as has been previously directed by the Board of Commissioners.

The management of the Town EMS Department would be identical to that of all other Town departments, the EMS Chief would report directly to the Town Manager, and the new department would ultimately be accountable to the Board of Commissioners.  Under this model, a separate Board of Directors is unnecessary, and the Board of Commissioners would serve as the “ultimate Board of Directors”, as it does for all other Town departments, including Police, Fire, and others.   

This model would result in improved communication and coordination with other Town departments, and likely result in other operational efficiencies.  The Town will have complete discretion to implement desired service improvements in the future, and will be able to more fully consider these services in the context of the entire Town organization.  The Town would continue to welcome and encourage EMS volunteers to assist in any way desired by the volunteers.  It is anticipated that EIEMS, Inc. would continue to exist as a separate organization that supplements paid personnel, serves as an EMS advisory Board to the Chief, Town Manager, and Board of Commissioners, and engages in fundraising activities.   

The total annual cost associated with this model (which includes improved benefits for EMS employees and the additional full-time position created by EIEMS, Inc. in May 2017) is estimated at approximately $630,000.  Essentially, this service model includes similar costs as the continued contract relationship, plus the additional cost for improved benefits for each full-time employee.  These additional costs can likely be accommodated in the Town’s existing budget.    

As noted, this service model is also unusual, and I am unaware of any other municipal EMS-only departments in North Carolina.  The Board of Commissioners should note that the Town has pursued this service model specifically and only because EIEMS, Inc. has repeatedly noted that it opposes a transition to County government and that it opposes a transition to a combined Fire & EMS department.  In an effort to be cooperative with EIEMS, Inc., the Town has focused its efforts solely on the establishment of a Town EMS department, regardless of other cost, service quality, or efficiency concerns. In short, the Town has deliberately worked to accommodate EIEMS, Inc. on this issue, and has intentionally placed greater emphasis on their concerns than other cost, service quality, or efficiency concerns in order to promote a cooperative transition.     

In Emerald Isle, proponents of this service model might claim that:

  • this service model places the highest priority on accommodating EI EMS, Inc.’s concerns while also improving accountability for significant sums of public funding,
  • this service model is sustainable in the long-term, and retains control of emergency medical services in the Emerald Isle community,
  • a clear focus solely on emergency medical services would result in better quality service, and that service providers would not be “distracted” by fire or other duties,
  • the integration of EMS services into the Town organization will improve communication and coordination with other Town staff, and
  • existing EI EMS, Inc. employees would become Town employees in a municipal EMS department and would receive improved employee benefits.

In Emerald Isle, opponents of this service model might claim that:

  • some other service model options (County-wide EMS, combined municipal Fire & EMS, or hospital-based) are likely to be more efficient and as or more effective in providing quality services,
  • this service model has a slightly higher cost, due solely to the provision of improved benefits for EMS employees,  
  • EMS fundraising activities will decline if service is provided by a Town

    department, and

  • volunteers may not be interested in serving a Town EMS department.

Although cost is absolutely important in the provision of emergency medical services (and all Town services), it has not been viewed as the sole factor in the decision-making process for emergency medical services.  The reality is that each of these service models is affordable for the Town of Emerald Isle, and the key factors considered in this decision-making process have always been accountability, good government, service quality, and long-term sustainability.  The reality is that the current service model is not sustainable in the long-term, and both the Town and EIEMS, Inc. have known this and have been gradually evolving to an alternative service model for many years.  If the Board of Commissioners does not make a change to the EMS service model this year, it is likely only a matter of time before this issue resurfaces again in the future. 

Rationale for Transition of EMS to Town Department

Much of the rationale for the transition of EMS to a Town department has been discussed above, however, I will summarize the key reasons for this effort below.  As you will note, most of these are “big-picture” items:

  • emergency medical services are no longer provided by a true volunteer organization (and have not been for many years), and EIEMS, Inc. has evolved into a fully-paid, non-profit organization that now operates with an annual budget of nearly $600,000 of public funds,
  • the core volunteers who “built” EIEMS, Inc. over several decades are no longer active, have moved away, or, in some cases, have passed away; the organization is not the same organization that it was for much of the Town’s and EIEMS, Inc.’s  history,
  • there are now only a small number of volunteers actually providing emergency medical services, and this complex organization is primarily governed by leaders selected by a very small group of volunteers,
  • the current service model is not sustainable or prudent in the long-term,
  • it is unusual for such an organization serving a community of people as large as Emerald Isle to operate under the current service model,
  • the Town directly provides the bulk of funding for EMS operations, and has only limited input into the management of the EIEMS, Inc. organization,
  • the current service model does not maximize cooperation and communication with other Town departments, and the Town may be missing unknown opportunities for greater service efficiencies and service enhancements,
  • the perception by many in the Emerald Isle community is that EMS is already part of the Town government organization,
  • the Town already performs financial administration and payroll services for EI EMS, Inc.,
  • the Town owns the EMS station and has funded the purchase of many of the existing assets, and
  • the fact that other Town departments providing important public services with similar amounts of significant public funding are not governed by a separate Board of Directors, and are accountable to the people of Emerald Isle through the Town government and ultimately the elected Board of Commissioners.

Additionally, there has been increasing concern about the management of Emerald Isle EMS, Inc. in recent months and a perceived lack of communication and cooperation with the Town, which is the contracting entity and is ultimately responsible for the provision of emergency medical services in Emerald Isle.  Some of the more recent and specific concerns that have reinforced the rationale noted above include the following:

  • there have been more instances in recent years in which EIEMS, Inc. has made significant decisions despite the concerns of the Joint EMS Committee and/or the Board of Commissioners, and/or has proceeded with initiatives that will impact the Town budget in the future without first seeking approval; examples include:
    • inconsistencies in the need for (or lack of need for) a full-time EMS Chief position,
    • the creation of an additional full-time position after assuring the Town that no new full-time positions would be created when the full-time EMS Chief position was created earlier this year,
    • the purchase of new equipment and incurring debt without Town approval, for which the Town is expected to fund debt service payments,
    • the purchase of additional equipment after incurring debt for other equipment,
    • proceeding with the direct solicitation of donations from Emerald Isle taxpayers that fund the majority of EMS services despite concerns expressed by the Town, and
    • incurring expenses to purchase new uniforms and create a new website just weeks before the transition to the Town organization.
  • there have been concerns about personnel decisions in the past year, including the dismissal of the previous Chief for undisclosed reasons, the apparent fast-tracking of the new Chief selection process soon thereafter in January, and later ignoring Town suggestions to delay the selection of a new EMS Chief and then proceeding with the selection of a new EMS Chief in May 2017 even after the Board of Commissioners specifically stated its intent (in April 2017) to transition EMS to a Town department by March 1, 2018,
  • previous statements (in early 2017) attributed to some EIEMS, Inc. leaders suggesting that existing EIEMS, Inc. assets, which were purchased by the people of Emerald Isle (regardless of whether funding is derived from tax revenues, service fees, donations, or fundraising initiatives), might be given to other EMS service providers outside of Emerald Isle if / when EMS became a department of the Town government organization,
  • there has been a lack of responsiveness to recent Town requests for information, including ignoring Town requests for budget information associated with the new full-time position, the implication that such decisions are none of the Town’s business, the inability or reluctance to provide a copy of the EMS billing policy after several requests since the summer, and other delayed responses to Town requests for information, and
  • there has been confusion about decision-making authority in the EI EMS, Inc. organization, and the implementation of the new service model will clarify decision-making authority.   

As you know, the Board of Commissioners made the decision to proceed with the transition of EMS to a Town department in April 2017 after more than a decade of discussion about this issue.  Additionally, the Town has been encouraged by some of the core volunteers who built EIEMS, Inc. that the time is now right to proceed with the transition of EMS to the Town government organization.  As noted above, if the Board of Commissioners chooses not to proceed with this transition now, it is likely only a matter of time before this issue resurfaces again in the future.  The Board of Commissioners should also note that as service demands continue to increase and as volunteerism continues to decline (for completely understandable reasons), there will almost certainly be requests for additional Town funding and the creation of additional full-time and part-time positions to provide emergency medical services in Emerald Isle in the future.  The Board of Commissioners should contemplate exactly how large a separate, non-profit organization that relies almost exclusively on public funding should ultimately become, and should insure that prudent accountability mechanisms are in place.   

Until recent weeks, the EIEMS, Inc. Board of Directors had appeared to publicly embrace this transition, however, concern was recently expressed about the Board of Commissioners’ directive to utilize a competitive selection process for the Town EMS Chief.  Because they disagree with this approach, at least one member of the EIEMS, Inc. Board of Directors has now publicly expressed opposition to the transition of EMS to a department of the Town government organization.  As the Town Manager is charged with the selection of all Town department heads, I have repeatedly assured all involved that the current EIEMS, Inc. Chief will receive fair consideration for the Town EMS Chief position, and I have encouraged him to apply and compete for this position in the same manner that we anticipate that others will apply and compete.  As noted numerous times in the past, I intend to utilize an inclusive selection process that will include input from other Town department heads, other EMS professionals in North Carolina, and the EMS staff. 

The Board of Commissioners should note that a competitive EMS Chief selection process was included in the February 2017 framework for the new EMS department that was presented to the entire EIEMS, Inc. organization in February and March.  Ironically, this approach was included in the February 2017 framework because EIEMS, Inc. specifically requested that the Town undertake a competitive selection process.    

Status of Transition Efforts

As you know, the Board of Commissioners decided to proceed with the EMS transition at its April 12, 2017 meeting, just as the busy tourism season was about to begin.  Because of the significant increase in workload for both EIEMS, Inc. and Town staff during the tourism season, the bulk of the work associated with the transition was intentionally delayed until the fall.  Town staff began preliminary work on transition efforts during the summer, and more concerted efforts by Town staff began in early October and are ongoing. 

The Joint EMS Committee met on November 3 to review the list of tasks to be completed to implement the transition.  An updated copy of that list (November 22) is attached for the Board of Commissioners’ information.  As you will note, nearly all of the tasks are administrative in nature, and can be completed by Town staff with appropriate assistance from EIEMS, Inc. officials and staff.  This list is shorter than might otherwise be necessary due to the fact that the Town already provides financial management and payroll services for EIEMS, Inc., and many of the remaining tasks on the list will be completed by or led by Laura Rotchford, Finance Director, and/or Rhonda Ferebee, Town Clerk / Human Resources Specialist.  With proper cooperation from EIEMS, Inc., I don’t foresee any significant impediments to completing these tasks by March 1, 2018.

Rhonda Ferebee and I have held individual meetings with all 6 of the current full-time EMS employees serving as Paramedics and EMTs.  I have communicated to each employee that they are valued by the Town, will be transitioned to a full-time employee of the Town, that their salary will not decrease, their job duties will be nearly identical to their current job duties, their job titles will not change, and their benefits package will be consistent with the benefits provided to all other Town employees.  The Town’s benefit package includes a more robust health insurance plan and a better retirement program, and thus the EMS transition will be especially beneficial for the full-time EMS employees.  All 6 employees expressed a willingness and/or enthusiasm about becoming a Town employee, and we enjoyed meeting with each of them.  Additional meetings with the employees will be coordinated by Rhonda Ferebee in the coming weeks.  

I also met with the current Chief to explain the new Chief selection process, encouraged him to apply and compete, and explained to him that if he is selected as the Chief, then he will be treated in the same manner as described above.  I also explained that if he is not selected as the Chief, from my perspective as Town Manager he is still welcome to remain with the Town EMS Department as a Paramedic, at the appropriate salary range.  I made this commitment to him to be compassionate and in recognition of his family responsibilities, even though this approach is temporarily more costly for the Town.  (My approach is to retain this additional position until attrition occurs, at which time we would not fill the future vacated position.)  If the Board of Commissioners is not comfortable with this approach, please provide appropriate direction and I will adjust accordingly.  The Board of Commissioners should note that the current Chief is also employed by the EMS billing company that provides services for EIEMS, Inc., and this employment is not consistent with Town policy.  I advised the current Chief that in whichever role he may fill for the Town that he will be required to separate from his employment with the current EMS billing company.

I have also communicated with the current EMS part-time employees to explain the transition and offered to answer any questions they may have.  Part-time employees of the Town are not eligible for benefits, and these employees only work sporadically for EIEMS, Inc., so the transition issues are less complex for these employees.  I did communicate to the group that each part-time employee is valued by the Town, will be transitioned to a part-time employee of the Town, that their hourly rate will not decrease, their job duties will be nearly identical to their current job duties, and their job titles will not change.  Many of the part-time employees are employed in a full-time capacity in other public safety departments in our region (that utilize the other EMS service models discussed earlier), and I expect that most, if not all, will continue to work part-time for the Town in the future.

Perhaps the other most significant task to be competed is the recruitment and selection of the EMS Chief.  Advertisements have been published in several media, and the deadline for applications is Thursday, December 21.  (A copy of the “long version” of the EMS Chief advertisement is attached.)  Rhonda Ferebee and I are hopeful that the Town will attract numerous qualified applicants.  As is the case for all Town department heads under the council-manager form of government, the Town Manager will ultimately select the EMS Chief.  As noted above, however, I will be utilizing an inclusive selection process that will include input from other Town department heads, other EMS professionals in North Carolina, and the EMS staff.  I hope to schedule interviews and activities for the selected finalists in mid-January, and announce a selection before the end of January.   I am hopeful that EMS Chief will begin work with the Town just prior to the March 1 transition date.  

As noted numerous times in recent months, and for the past decade+ that the EMS transition has been discussed, the Town absolutely welcomes and encourages any and all volunteers who are willing to provide their time and talents to assist the Town EMS Department.  As noted earlier, for many reasons not unique to Emerald Isle, volunteerism has declined over the past few decades, however, Emerald Isle is fortunate to receive services from a small, but dedicated group of volunteers.  I hope those efforts will continue, and all volunteers are absolutely welcome and encouraged to serve the Town EMS Department.  Perhaps the most significant task to be completed by EIEMS, Inc. is the exact form and roles of the volunteer organization in the future, and I am essentially relying on EIEMS, Inc. to determine the most appropriate form according to their goals, subject to the following basic parameters: 

  • the EMS Chief is responsible for the day to day management of the Town EMS Department and the supervision of all EMS personnel, 
  • the Town Manager is responsible for the selection and oversight of the EMS Chief,
  • any volunteer fundraising proceeds must be deposited and managed by the Town’s Finance Director in Town accounts, but will be effectively segregated and limited to use for EMS expenses only, and
  • the Board of Commissioners is responsible for all funding and expenditure decisions for the Town EMS Department (these basic parameters are consistent with those used by all other Town departments). 

As I have communicated repeatedly to all involved, I will absolutely expect the EMS Chief to cultivate a positive and productive relationship with the EI EMS, Inc. volunteer organization and maximize their involvement in any way that is beneficial for our residents and visitors, the volunteers, and the Town EMS staff. 

As noted, the exact form and roles of the volunteer organization will be determined by themselves, however, I have suggested that the volunteer organization might perform the following roles:

  • supplement paid EMS staff as desired and advantageous for the volunteers and the Town, under the direction of the EMS Chief,
  • serve as an advisory body to the EMS Chief, the Town Manager, and the Board of Commissioners on EMS issues in Emerald Isle,
  • engage in fundraising activities as desired, and
  • any other beneficial roles not inconsistent with the Town’s goals.

The next Joint EMS Committee meeting will be held on Friday, December 15, and other meetings will be scheduled as needed in the following weeks.  In the meantime, I remain in regular communication with Town staff assigned the various duties necessary to implement the EMS transition.  I remain optimistic that all necessary tasks associated with the transition will be complete by the March 1 deadline, however, if any tasks are not fully complete by that date we will adjust accordingly.  

Conclusion

Ultimately, the responsibility for emergency medical services in Emerald Isle rests with the Board of Commissioners, and the Board of Commissioners is authorized to utilize any legal service model to ensure the most cost-effective and highest quality services are afforded to our residents and visitors. 

Town staff have been working to implement the Board of Commissioners’ April 2017 directive to establish a Town EMS Department, and will continue efforts to implement this service model unless directed otherwise.  I also anticipate presenting several administrative items associated with the transition to the Board of Commissioners for consideration at future Board of Commissioners meetings.    

I look forward to updating the Board of Commissioners on this issue at the December 12 meeting, and welcome any constructive feedback and suggestions you may have so that Town staff may more effectively implement your directive.