Regulation and Licensing of Medical Transportation Services

The Emergency and Protective Services Committee recommends:

(1)the adoption of the following report (January 18, 1999) from the Commissioner of Works and Emergency Services; and

(2)that representatives of the Toronto Ambulance Service Staff Association, the Canadian Union of Public Employees, Locals 79 and 416, and the Operators Association be invited to assist in the development of the proposed regulations:

Purpose:

To advise Toronto Council of Bill 86, 'An Act to provide for better local government by updating and streamlining the Municipal Elections Act, the Municipal Act and related statutes'. This legislation empowers municipalities, at their option, to effect both service standards and regulation of Medical Transportation Services. Despite Medical Transportation Services being defined in legislation, without such municipal regulation, providers are free to operate without consistency or measurable objectives for public safety. In addition, through Toronto Licensing, as with other vehicles offered for hire in the municipality, consideration may be given to licensing the owners and drivers of medical transportation vehicles.

Funding Sources, Financial Implications and Impact Statement:

Licence fees set at cost recovery levels for medical transportation services would have a neutral funding impact on Toronto Licensing. However, there will be resource implications to implement and sustain the processes of licence issue and enforcement. At least thirty medical transportation services are in operation Province-wide, with approximately ten to twelve operating in the Greater Toronto Area. Regulating and licensing these providers will ensure a safe and acceptable level of service and an appropriate alternative for citizens requiring transportation by other than ambulance services as defined under regulation.

Recommendations:

It is recommended that:

(1)the City Solicitor and Commissioner of Urban Planning and Development Services, in consultation with Toronto Ambulance, define and construct regulations and set standards (see attached draft guidelines) that will regulate Medical Transportation Services within Toronto;

(2)a process of public meetings and focus groups be established in the community to provide the public and other service providers and stakeholders with an opportunity for input and comment on the regulatory, licensing process, or formal business;

(3)the City Solicitor evaluate the Municipality's risk/obligations/options around the regulation/licensure of this new transportation sector; and

(4)the appropriate City officials be vested with the necessary authority to give effect thereto.

Council Reference/Background/History:

The omnibus legislation Bill 86 received Royal Assent on December 19, 1996. Part X.2, section191.6(1) amends the Highway Traffic Act, empowering municipalities to regulate Medical Transportation Services by setting standards in relation to the operation of those Services. Since 1994-1995, twenty eight to thirty Medical Transportation Services have come on-stream across the Province with ten to twelve operating in the Greater Toronto Area. Section 191.6(3) provides for fines of not more than $10,000.00 on conviction of contravention of such a by-law. Section 191.7 ensures that the Minister of Transportation may make regulations designating the types of services and vehicles.

Furthermore, Part III Section 59(10) of Bill 86 also amends the Ambulance Act as follows:

Ambulance Act:

"Ambulance" means a conveyance used or intended to be used for the transportation of persons who,

(a)have suffered a trauma or an acute onset of illness either of which could endanger their life, limb or function, or

(b)have been judged by a physician to be in an unstable medical condition and to require, while being transported, the care of a physician, nurse, other health care provider, emergency medical attendant or paramedic, and the use of a stretcher;

"ambulance service" means a service, including the service of dispatching ambulances, that is held out to the public as available for the conveyance of persons by ambulance.

(A)Comments and/or Discussion and/or Justification:

Impacts:

(a)The new definitions contained in the Bill 86 Ambulance Act amendments (see above). If all three ambulance transport criteria, i.e., unstable, stretcher required and patient in need of an escort were applied literally, this could polarize more requests for non-emergency ambulance service to the medical transportation sector.

(b)Declining non-emergency call volumes. Note: 1994 non-emergency call volumes decreased significantly. It is feasible that 5,000-6,000 per annum have moved to the Medical Transportation Services sector since their inception.

(c)Ambulance service must maintain its 'ready status' for emergency response. Although hospitals prefer to use ambulance services because it is less costly, tight time demands for diagnostic and other specialized procedures see them opting to use Medical Transportation Services whom they perceive as more sensitive and responsive to those non-emergency but time-sensitive needs.

(d)More frequently Ambulance Call Reports are being signed-off as non-essential by the medical community, which in turn results in the generation of a $240.00 billing.

(e)More uninsured or ineligible ambulance billings of $240.00. Due to the more specific new Ambulance Act definitions, more calls for service provided by ambulance but deemed ineligible for Ontario Health Insurance co-payment could cause a further shift of non-urgent call volume (possibly 5-15 percent) to the Medical Transportation Services sector as their average local transport billing rate by comparison is $60.00-$80.00. Many institutions are not aware that Medical Transportation is unlicensed/unregulated.

(f)Billing issues aside, non-emergency and non-essential calls, traditionally part of the ambulance service mandate, could shift to Medical Transportation Services. Already, they are perceived as faster (anecdotally) than the ambulance response to non-urgent transportation requests

(g)In an environment of increasing emergency call demand, overall acuity of illness and static health care funding envelopes, the option to use Medical Transportation Services could be seen as more attractive by institutions and the general public thus increasing pressure on governments and institutions to fund this alternative level of service.

(h)For inter-institutional transfers, the normal ambulance fee of $45.00 is waived. Already, Medical Transportation Services bills submitted as third party claims to medical insurers are frequently paid, indicating that no real distinction is drawn (at least by insurance providers), between the two types of service.

(i)From an institutional sector perspective, Medical Transportation Services represent an optional/partial solution to blocked acute care beds and missed 'time-sensitive' medical/diagnostic appointments or subsequent sub-acute or rehabilitation admissions elsewhere in the system. Development of regulations and standards would enfranchise the medical transportation sector as bona fide service providers.

(j)Aging population/demographic demands will inevitably increase pressure on the land ambulance system to perform more essential non-emergency services.

(k)Future co-shared opportunities might include non-emergency billing or fee for service, apportioned between Institutions, Municipalities, Patients and the Provincial Government.

History:

Since 1994-1995, 28-30 Medical Transportation Services have come 'on-stream' across the Province with 8-10 operating in the Greater Toronto Area.

Actions:

(a)Draft Ministry of Health Medical Transportation Services Safety Guidelines March21, 1997 (attached).

(b)Background sent to Ms. Shirley Mathi at Legal Services and Ms.CarolRuddell-Foster at Toronto Licensing on June 10, 1998, for review and consultation. Note from Ms. Shirley Mathi: TTC have exclusive mandate for transportation in Toronto.

(c)Toronto Fire Department charge $300.00 for 'assist' calls from Medical Transportation Services providers. See Toronto Fire Department Advisory May 25, 1998 (also attached) from Chief Speed.

Types of Patients/Client Eligibility:

Medical Transportation Services: Patient must be in stable condition but unable to tolerate sitting or standing, thus precluding wheelchair transport option. Could include frail, elderly, especially without own wheelchairs.

(B)Discussion: Cross-Sector Community Transportation Dispatch/Brokerage:

Ambulance service, medical transportation services, specialized accessible transit (including Wheeltrans) and community transportation (not for profit and volunteer) resources, accessible and otherwise, represent the continuum of transportation options available for medically necessary, through non-essential services available in the community.

A suggestion originating with the Toronto Social Planning Council in 1997 is that "a group investigate shared dispatching" potential between Wheel-Trans, Toronto Ambulance and other selected agencies (e.g,. Canadian Red Cross).

Low-priority requests for transportation service received by Toronto Ambulance Communications Centre could, subject to the necessary protocols, be redirected elsewhere within this continuum. Specifically, per Bill 86, those patients not requiring all three ambulance transport criteria, i.e., patient stable, stretcher not required and not in need of an escort (as defined, e.g., by a physician, other health care provider EMA, paramedic etc.)

In theory, it would be possible for one agency with the appropriate technical platform and expertise to receive and devolve all types of transportation requests to the appropriate level of resource, e.g., the 9-1-1 emergency number, or similarly in the private sector 967-1111 central number for pizza. Devolution would of course be contingent upon the necessary education, orientation of users/stakeholders and their "top-down" buy-in, together with an elective transportation algorithm crafted for public consumption and education.

The structure of this model would also need to demonstrate flexibility and encourage acceptance by the partners, including institutions, i.e., by providing dedicated transfer co-ordinators to optimize ''bed to bed" or "door to door" service. This would facilitate single or block bookings for groups requiring transportation service and access to all categories of service provider, on time without overlap or duplication.

Regulation of medical transportation services, followed by focus group sessions including the community transportation sector, accessible transit and out-of-hospital providers would represent a definitive first step in the development of scope of practice guidelines, public information and education material design and distribution to raise public awareness of and how to access the transportation options available.

Billing, cost-sharing and cost-recovery mechanisms, geared to the level of service provided, would be a necessary next step. Other communities, Upper Tier Municipalities are investigating the feasibility of setting the fees for medical transportation e.g., at $45.00. This would narrow the disparity between fees charged.

(C)CTAP:

This one time inter-ministerial program started out with $3 million, at < $50,000.00 per approved project and approximately 60 proposals from community groups around the Province. The objective, through the collaborative efforts of the inter-sectoral working groups, is to improve local access to transportation through more efficient and effective use and co-ordination of currently available resources.

Ongoing Community Transportation Action Program (CTAP) projects have shown that new partnerships are resulting in better utilization of elective transportation resources overall. Most have aimed at matching the right client with the right resource to achieve the best possible efficiencies, price and quality.

The CTAP Program, extended July 13, 1998, by Transportation Minister Tony Clement, now expires September 1999. Sustainability of services may then be in question. The Ministry of Health Long Term Care Division does provide transportation funding, i.e., the Long Term Care Division funds many agencies and institutions in the Province to provide transportation services to their own residents and clients. No municipal funding is received. Some not for profit sector agencies and volunteer transportation services are also variably dependent on grants and donations to help provide these services.

(D)Conclusions:

The provincial government's decision to devolve regulatory authority for Medical Transportation Services to municipalities may represent an opportunity to enhance public safety by setting standards for the safe operation of those services already operating within the community.

The City of Toronto, by virtue of its licensing authority could opt to impose appropriate minimum standards to ensure that the safety of medical transportation vehicles, adequate insurance coverage and driver qualifications are both met and maintained.

Contact Name:

R.L. Kelusky - 392-2200

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Medical Transportation Safety Guidelines Project

Definition for Purposes of Regulation:

"For the purpose of Part X.2 of the Act, a medical transportation service is a service:

(a)which is not licensed as an ambulance service under the Ambulance Act;

(b)which charges a fee or receives public or private funding;

(c)which offers to the public a combination of transportation and provision of care for the passenger's individual health care needs."

Guidelines

(A)Service Providers (the person or persons who provide direct service to the client - where a service uses one service provider as both a driver and health care escort all of the following guidelines apply to that provider).

All:

(1)Must be able to speak English.

(2)Must be free of those communicable diseases which have been determined by the Medical Officer of Health to be easily transmitted to the clients of the service through the normal interaction between the driver and the clients.

(3)Must provide a Criminal Record Search.

Driver:

(4)The driver of a medical transportation vehicle must have a current and valid driver's licence for that class of vehicle as specified in the Highway Traffic Act.

(5)Must have the skills necessary to carry out the driving tasks associated with the type of vehicle being used and the needs of the clients being transported.

Health Provider:

(6)Must possess the knowledge, judgment, and skill to recognize a medical emergency and render CPR and first-aid at an advanced level as defined by Federal or Ontario Ministry of Labour standards.

(7)Must have the training and credentials necessary to provide the level of care held out to the public by the medical transportation service.

(B)Client Care:

(1)The medical transportation service must not commence transportation of a client who requires an ambulance and must immediately contact ambulance dispatch in order to determine an appropriate course of action if it appears that a client has become or is becoming medically unstable during transport. (See Ambulance Act)

(2)Where there is reason to believe that a client is confused or disoriented, or is likely to require immediate care or assistance the client must be left in the care of an apparently responsible adult who is made aware of the problem.

(C)Communications:

(1)The person or persons providing service on the medical transportation vehicle must be able to contact ambulance dispatch and/or 9-1-1 (where it exists) from the medical transportation vehicle while a trip is in progress.

(2)The person or persons providing service on the medical transportation vehicle must know the telephone number for reaching ambulance dispatch in all areas of operation.

(3)The person or persons providing service on the medical transportation vehicle, upon arriving at a facility, must notify a member of that facility's staff that the client has arrived and the status of the client.

(D)Lifting and Moving Equipment for Clients:

(1)Wheelchairs, ramps and lifting devices provided by the medical transportation service must be maintained in good working order and must conform to Canadian Standards Association.

(2)Stretchers provided by the medical transportation service must be maintained in good working order in accordance with the Original Equipment Manufacturers specifications.

(3)Stretcher retention systems must be matched to the stretcher being used and must be maintained in good working order according to the Original Equipment Manufacturers specifications.

(E)Vehicle:

All:

(1)Must successfully complete annual safety inspections.

(2)Conform to the Motor Vehicle Safety Act.

Wheelchair:

Must conform to Canadian Standards Association standard CAN3-D409-M84 (Motor Vehicles for the Transportation of Physically Disabled Persons).

Must conform to Regulation 629 (Vehicles for the Transportation of Physically Disabled Passengers), Ontario Highway Traffic Act.

Stretcher:

(1)Easy loading of stretcher clients by means of a door or doors at the rear of the vehicle, and easy loading of ambulatory clients by means of a door or doors on the right side.

(2)Any door opening into or out of the client compartment shall be designed and equipped to permit such door to be opened from the inside of the vehicle, and such opening mechanism shall:

(a)contain instructions for the opening thereof on or adjacent thereto; and

(b)be designed to prevent inadvertent opening.

(3)A lap-type safety seat belt conforming to the standards prescribed in the regulations under the Motor Vehicle Safety Act (Canada) shall be provided for each seating position in the vehicle, and such belt locking mechanism and mounting device shall be properly maintained and in good working order.

(4)Adequate temperature regulation and ventilation.

(5)Interior lighting adequate for the care of clients.

(6)A rear flood light designed and attached to light the area immediately to the rear of the ambulance automatically upon opening of the rear door or doors.

(7)Storage for equipment to prevent or minimize projections and sharp edges, and to keep such equipment readily available for use.

(8)For the placement and transport of at least one sitting client when only one stretcher is in use.

(9)For seating in the client compartment for at least one service provider with one such seat at the head of the stretcher client.

(10)Have an interior that is free of any sharp projections that may constitute a hazard to passengers.

(11)Have permanently bonded to the floor in the client compartment in the aisle and on the steps, floor covering that is fire-retardant, skid-resistant and wear-resistant rubber or equivalent material.

(12)Have yellow or white step nosings.

(13)Conform with Canada Motor Vehicle Safety Standard 302 regarding flammability.

(14)Be equipped with at least one dry-chemical-type fire extinguisher:

(i)bearing the label of a recognized testing agency;

(ii)showing a rating of not less than 2-A; 10-B; C; and

(iii)equipped with a pressure gauge indicating that the fire extinguisher is adequately charged.

contained in the extinguisher manufacturer's bracket.

(15)Be equipped with an axe or clawbar.

(16)Be equipped with a unitized first aid kit in a sturdy, dustproof removable container containing:

(i)packets, containing hand cleanser and gauze cleansing pads;

(ii)adhesive dressings, individually wrapped;

(iii)compress dressings;

(iv)eye dressing kits;

(v)gauze dressings;

(vi)gauze bandages;

(vii)adhesive tape;

(viii)triangular bandages;

(ix)splint;

(x)one pair of scissors;

(xi)one pair of silver tweezers;

(xii)safety pins;

(xiii)manually operated suction apparatus with catheter; and

(xiv)Oropharyngeal airways in large, medium, and small sizes.

(17)The fire extinguisher, first aid kit, and axe or clawbar shall be mounted or secured in a location readily accessible to the driver and, if not in plain view, the location thereof shall be plainly marked.

(18)Be equipped with a means of securing in the open position, each passenger access door or emergency exit door that could be subject to unintentional closing during the loading or unloading of passengers.

(19)Be equipped with an interior mirror designed to provide the driver with a view of the passengers.

(20)Be equipped with lights arranged to illuminate all of the interior of the vehicle that shall be constantly lit during the loading or unloading of passengers.

(21)At least one door for passenger access and an emergency exit door located on different walls of the vehicle, and the emergency exit door shall be operable from both inside and outside the vehicle.

Multi-Purpose:

If a medical transportation vehicle is used for transporting a variety of clients with varying mobility needs (ambulatory clients, wheelchair clients, or stretcher clients) the vehicle must comply with the guidelines associated with each type of client.

Insurance:

The operator of the medical transportation service must carry adequate liability insurance.

The Emergency and Protective Services Committee submits the following report (January 20, 1999) from the Commissioner Works and Emergency Services:

Purpose:

The purpose of this report is to inform the Emergency and Protective Services Committee and Members of Council regarding the role and responsibility of Toronto Ambulance, as specified under the Ambulance Act of Ontario and its Regulations pertaining to the transportation of non-emergency patients within the City of Toronto.

Funding Sources, Financial Implications and Impact Statement:

There is no direct financial impact arising out of this report, however, future recommendations pertaining to licensing and regulation of private patient care transfer services and the enactment of the changes to the Ambulance Act Regulations may have a marginal impact on expenditures related to the delivery of out of hospital care and transportation within the City of Toronto.

Recommendation:

It is recommended that the following report be received for information by the Emergency and Protective Services Committee.

Background:

At its meeting on January 19, 1999, the Budget Committee received a deputation from the operator of Direct Care Patient Transfer Services. This firm is one of several unlicensed and unregulated private transfer providers operating within the City of Toronto. In his deputation to the Budget Committee, the deputant indicated the City of Toronto could save up to $14 million in the funding of its land ambulance service if the non-emergency transfers currently provided by Toronto Ambulance are brokered to private patient transfer services. This calculation was based on a formula of multiplying the 60,000 patient transfers currently provided through Toronto Ambulance by an average cost per call of $240.00.

The deputant further stated that the qualifications of the staff engaged in providing private patient transfer services are identical to the level of training of Toronto Ambulance paramedics and that all patient transfers currently provided by Toronto Ambulance could be safely moved by alternate means. The deputant concluded the shift of non-emergency transfers to private firms could free up ambulances for more important emergency calls and result in reduced expenditures on the cost of providing ambulance service within the City of Toronto.

Comments and/or Discussion and/or Justification:

Currently, Toronto Ambulance moves approximately 60,000 non-emergency patients on annual basis. Non-emergency transfers encompass movement of patients from institutions to institutions or specific medical treatment, homes to institutions for treatment and/or admission, and from institutions to home following discharge. Approximately 50,000 of the 60,0000 patients are transferred during the period Monday to Friday from 7 a.m. to 7 p.m. The balance of the transfers, approximately 20percent or 10,000, are transferred during the weekend or at night.

Toronto Ambulance has organized its non-emergency transfer program to handle the bulk of the patient transfers on the Monday to Friday basis. Currently, there are approximately 40 staff engaged in this program operating between 10 and 12 ambulances per day. The total costs of providing non-emergency transfer program on a Monday to Friday basis is approximately $3.3 million, inclusive of salary, wages, vehicle costs and relating operating expenses. The balance of the non-emergency transfers, or approximately 10,000 per year, are handled out of the regular ambulance fleet and weekends and nights. These transfers are provided in the marginal surplus capacity that exists within the deployment plan. It would suggest that the overall costs, savings and/or expenditures related to providing non-emergency transfer services by Toronto Ambulance is $14million and is not a correct calculation based on the manner in which Toronto Ambulance has organized its non-emergency patient transfer program.

Further, if the Ambulance Act and its Regulations permitted all transfers to be serviced by private transfer providers, the total savings to the City of Toronto and the ambulance services could be less than $3.3 million. This would only account for resources assigned to the non-emergency patient transfer program on a Monday to Friday basis. There would be no savings derived by eliminating transfers on weekends and nights as these transfers are carried by utilizing marginal surplus capacity within the emergency ambulance fleet.

Private fee-for-service transport companies raise an important public policy and social justice issue. The elderly, the ill and the disabled rely heavily on our non-emergency services, which are provided without user fees from the municipal tax base. Any transition to "user pay" services imposes a disproportionate burden upon those who can least afford it.

While the City itself might shed $3.3 million by ending its non-emergency ambulance services, we should be acutely aware that it would download that cost directly on those least able to afford it. If City policy creates a service accessible only to the wealthy, we would set a dangerous precedent in "two-tiered" health care, with a public system for the poor, and a private system for the well-to-do.

Similarly, contracting out this portion of our business, while paying for it from City taxes, would fail to make use of our paid-for infrastructure and introduce the cost of the private firm's profit as a new and avoidable cost.

The Ontario Ambulance Act and its Regulations, both current and proposed, place significant restrictions in the ambulance operator being able to delegate the responsibility of patient transfers in non-licensed ambulance services. The Act and its Regulations define a licensed ambulance service and this does not include private patient transfer services within its definition.

In addition, the proposed Regulations define the type of patient that can be transported by means other than a licensed ambulance service. Essentially, a patient that requires medical management, medical monitoring or has been determined by a medical practitioner to require medical supervision during transport, cannot be carried by a private patient transfer service. Patients who are eligible would only include patients who are otherwise healthy but because of some underlying physical restrictions, cannot be moved by wheelchair, vehicle, taxi and/or private car.

The Ambulance Act and its Regulations prohibit a licensed ambulance service from charging a non-emergency transfer services. The current rate for a private patient transfer service within the existing unregulated environment is approximately $65.00 to $80.00 per trip within the boundaries of the City of Toronto. These rates change depending on the distance travelled from the point of pick up. One of the issues to be reviewed as part of the process of regulating and licensing of these providers will be the establishment of a rate structure that is fair and equitable.

Of the total number of non-emergency patients transported by Toronto Ambulance between 10percent and 20 percent could fall under the category of being eligible for transport by private transfer services. This figure is based on an assessment of calls completed by Toronto Ambulance in previous years.

Since 1995, the number of non-emergency transfers serviced by Toronto Ambulance has remained stable at approximately 60,000 per year. It is recognized that the number of non-emergency patients have increased over this period and it is believed that much of this increase has been distributed amongst the existing eight to ten private unregulated providers operating within the City.

The Ambulance Act and its accompanying Regulations, combined with the rules and guidelines governing the types of patients that can be transported by private service providers will not result in a significant change in the demand placed on Toronto's ambulance service. Marginal reductions of 10 percent to 20 percent in the overall volume currently serviced by Toronto Ambulance will be offset by expected increases in emergency demand on an annual basis. Projections by the Emergency of Health, Emergency Health Services Branch, supported by the Ernst & Young review of ambulance services in 1996, indicated a two percent increase in emergency demand compounded annually over the proceeding ten years. Any surplus capacity generated through reduction in non-emergency demand would be necessary to partially offset projected increase in emergency calls.

The proposed regulation and licensing of non-emergency private transfer providers by the Municipality will ensure that those patients deemed eligible by a medical practitioner would be guaranteed a safe and competent transportation and a fee structure approved by the Municipality. It should be recognized that even though the regulation and licensing of these providers could offer an alternative to the municipal ambulance service, the fact remains that restrictions on eligibility still exist through the Ambulance Act and its Regulations.

Conclusion:

It is the intent of this report to provide Members of Council with information concerning the regulations and standard that affect that transportation of patients within the City of Toronto. Medically essential transfers where there is a requirement for medical monitoring and medical supervision of patients will continue to be provided by Toronto Ambulance and only those patients who are deemed to be stable by a medical practitioner and/or designate could be transferred by a private alternative service provider.

Contact Name:

R.L. Kelusky

Tel: 397-9241/Fax: 392-2115

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The Emergency and Protective Services Committee reports, for the information of Council, also having had before it a communication (February 8, 1999) from Ms. Anne Dubas, President, Canadian Union of Local Employees, Local 79, respecting the Regulation and Licensing of Medical Transportation Services; and requesting CUPE Local 79 involvement in the proposed process to determine standards, in order to ensure that appropriate safe and accessible transport is available to all patients.

The following persons appeared before the Emergency and Protective Services Committee in connection with the foregoing matter:

-Mr. David Allen, Ambutrans;

-Mr. Harro Bauer, Paramedic, Toronto Ambulance; and

-Mr. Marc Bilz, Paramedic.