To: Board of Supervisors of Sonoma County
Department or Agency Name(s): Department of Health Services
Staff Name and Phone Number: Tina Rivera, 707-565-4774
Vote Requirement: Majority
Supervisorial District(s): Countywide
Title:
Title
Emergency Medical Services Exclusive Operating Agreement Request for Proposal Revisions
End
Recommended Action:
Recommended action
A) Authorize the Director of Health Services, or designee, to submit the revised request for proposals (RFP) to California Emergency Medical Services Authority (EMSA).
B) Authorize the Director of Health Services, or designee, to make modifications necessary to secure approval of the RFP from California Emergency Medical Services Authority.
C) Authorize the Director of Health Services, or designee, to release the RFP for responses and to make non-substantial changes prior to the proposals due date.
end
Executive Summary:
On April 13, 2021 the Board of Supervisors deliberated on the proposed components of the draft RFP for Exclusive Operating Area #1 (EOA 1) for the purposes of submitting the RFP to the California Emergency Medical Services Authority (EMSA) for approval based on the provision of Sonoma County Code Chapter 28-17, adopted by the Board on November 12, 2019. At that meeting, the Board directed staff to submit the draft RFP to EMSA.
EMSA declined initial approval of the RFP, so staff worked with County Counsel, the Emergency Medical Services (EMS) Ad Hoc committee, and EndPoint EMS Consulting, LLC to revise the RFP to address the legal issues raised by EMSA. Staff also consulted with the Ad Hoc committee for guidance on how to best follow the policy direction of the Board when drafting any revisions to the RFP needed to gain State approval.
On November 2, 2021, the Board of Supervisors approved the language and timeline of the RFP and directed staff to publicly announce the RFP and solicit proposals for service consistent with the County’s purchasing policies. The RFP was publicly posted on November 8, 2021 with a proposal due date of March 1, 2022. Shortly after Board approval, staff submitted the RFP to the California EMSA which approved the RFP on February 8, 2022.
At a December 2, 2021 RFP proposers conference, the County received nearly universal feedback about the short implementation timeline, supply-chain challenges, and labor market difficulties. At the time, Staff noted these concerns and committed to monitoring these issues. As the proposal due date approached, staff recognized that the market issues were getting worse, so on February 18, 2022, CVEMSA rescinded the RFP with the intention of reissuing later in 2022.
The draft RFP, provided as Attachment 1, contains minor revisions recommended by California EMSA, revisions to recognize the active implementation of tiered ALS/BLS response, and revisions adopted from the stakeholder engagement and feedback sessions conducted after the RFP was rescinded in February 2022. Upon Board approval, staff will submit the RFP to EMSA to review and approve edits since their last approval. Staff believe the policy direction of the Board has been followed to ensure a fair and transparent process while conducting an RFP with the goal of procuring a highly qualified vendor from the widest possible group of proposers capable of serving the community.
Discussion:
Division 2.5 of the California Health and Safety Code (HSC) “the EMS Act” § 1797.224 allows Local EMS Agencies (LEMSA’s) to enter into formal agreements for provision of ambulance service through the creation of Exclusive Operating Areas (EOA’s). HSC 1797.224 states:
A local EMS agency may create one or more exclusive operating areas in the development of a local plan, if a competitive process is utilized to select the provider or providers of the services pursuant to the plan. No competitive process is required if the local EMS agency develops or implements a local plan that continues the use of existing providers operating within a local EMS area in the manner and scope in which the services have been provided without interruption since January 1, 1981. A local EMS agency which elects to create one or more exclusive operating areas in the development of a local plan shall develop and submit for approval to the authority, as part of the local EMS plan, its competitive process for selecting providers and determining the scope of their operations. This plan shall include provisions for a competitive process held at periodic intervals. Nothing in this section supersedes Section 1797.201.
Sonoma County designates the Department of Health Services (DHS, or “the Department”) as the LEMSA for Sonoma County. EMS Agency functions are the responsibility of Coastal Valleys EMS Agency, which is organized within the Public Health Division of the Department. In 1991, the LEMSA, under direction of the Sonoma County Board of Supervisors, established an EOA to serve the cities of Santa Rosa, Sebastopol, Rohnert Park, Cotati, and the surrounding unincorporated areas. At this time, this is the only EOA for ambulance service in Sonoma County. The County will be conducting its fourth request for proposals (RFP) since developing this EOA. The current emergency ambulance agreement has been extended to January 15, 2024.
Although the EOA as currently designated covers the densely populated center of the County, and the majority of Sonoma County’s 911 calls occur within that zone, much more of the geography of Sonoma County is outside of the EOA. The EOA is surrounded by a mix of provider agencies including city and district fire service providers that provide ambulance service, a community services district and a healthcare district as well as two private ambulance services. The agencies that provide service to their local communities rely on each other for mutual support and routinely collaborate with their neighbors on system issues that affect the entire County. Selection of a highly competent provider with sufficient capacity will help ensure timely and effective mutual aid when needed across the County.
In early 2018, Coastal Valleys EMS Agency (CVEMSA) and DHS created an RFP Development Project committee. The purpose of the committee was to receive input from interested stakeholders on the proposed structure of the RFP for Ground Emergency Ambulance Service within the Sonoma County EOA. The committee also provided valuable input into an updated EMS System Ordinance which included direction on EOA development and provider selection processes. Oversight of the ordinance revision process was provided by an EMS Ad Hoc committee established by the Sonoma County Board of Supervisors. The EMS Ad Hoc committee met regularly with DHS leadership and EMS Agency staff to provide guidance and policy direction. The Ordinance was adopted by the Sonoma County Board of Supervisors in November 2019.
Initial RFP Development Process
In October 2019, DHS contracted the services of EndPoint EMS Consulting, LLC (EndPoint) to assist the County in completing the RFP process. This included facilitating a stakeholder process, producing a draft RFP for Board approval, and assisting in the negotiations of an agreement with the successful proposer. EndPoint mapped out a three-phase process to achieve the goals of the County. Phase One has been completed, comprising a high-level system assessment and stakeholder input process. Phase Two, which is currently being conducted, develops, and conducts the ambulance EOA procurement process, and Phase Three will assists with contract negotiation and development with the awarded provider. Endpoint completed Phase One in July of 2021. Based on stakeholder input guidance from the EMS Ad Hoc committee, DHS developed a draft RFP for consideration by the Board of Supervisors.
During the RFP development process, the County’s EMS system participants: fire departments, ambulance providers, hospitals, and community leaders were offered an opportunity to provide input into the next ambulance RFP. In the process of working with stakeholders and county staff, a number of key areas of stakeholder interest were identified by the consulting team. During the RFP input sessions, Stakeholders expressed support for a more inclusive range of potential vendors to include public agencies seeking to complete, allowing for subcontracting of portions of the service delivery by the winning bidder and potential expansion of the EOA boundary. In addition to expanding the range of potential vendors, several other system- of-care enhancements were proposed by stakeholders and supported by the EMS Ad Hoc committee. These enhancements include:
1) Using advanced technology and the ability to leverage EMS data to drive quality improvement.
2) Setting expectations for clinical performance in addition to response time performance.
3) Limiting the exclusivity of the EOA to emergency ambulance services while allowing non-emergency ambulance services to market services to health system partners.
Following the March 23, 2021 presentation of the draft RFP to the Board of Supervisors, staff were directed to respond to a series of public comments made by system stakeholders. Staff brought revision recommendations to the EMS AdHoc committee for approval and for submission to the Board for final approval prior to seek state approval of the competitive process required by HSC 1797.224.
During the March 23, 2021 meeting, the Board also provided direction to accept the Ad Hoc committee’s recommendation to revise the EOA boundary which will exclude the proposed northern expansion of the EOA into the area currently and historically served by Bell’s Ambulance Service. The revised boundary proposed for submission to the California EMS Authority is reflected in the draft RFP to include the current EOA 1 zone and adding the West County community of Occidental and surrounding area noted in the 2018 EMS Plan VeriHealth (Falck) that has been vacant of a designated primary ambulance responder since June of 2020.
On April 13, 2021, staff returned to the Board with revisions to the RFP that addressed the issues raised in the public comment process. The proposed revisions were presented to the Board with the support of the EMS Ad Hoc committee. The Board authorized the Department to submit the revised RFP to the California EMS Authority for approval.
Steps Towards Board of Supervisors’ Approval
On April 15, 2021, the Department submitted the draft RFP to EMSA for review and approval. EMSA responded with a letter indicating the RFP was not approved as submitted. EMSA issues included:
1) The scoring process in the RFP allowed the County to award the Exclusive Operating Area to an entity other than the highest scoring proposer.
2) The RFP had different requirements for public and private proposers.
3) The RFP had inadequate evaluation scoring directions.
Staff addressed the EMSA concerns through the following revisions:
1) The RFP evaluation process will produce an awardee solely based on the scoring of the Proposal Review Committee. The independent panel selected in conformity with Sonoma County Code section 28-17 will review and score each proposal. The Department will draft a contract that is compliant with the terms of the RFP and recommend it to the Sonoma County Board of Supervisors for approval. If the Board authorizes the Department to enter into an agreement with the selected contractor, the resulting exclusive operating area agreement will meet state requirements for protection from anti-trust legal action in accordance with Health and Safety Code section 1797.224. The ultimate authority to enter into an agreement or not remains with the Board.
2) Structural revisions to scoring and additional clarification in RFP language. The scoresheet in the draft RFP has been improved through the addition of detailed scoring criteria and expanded references to RFP sections containing the required elements to be addressed in each proposal.
3) More granular scoring elements were added and scores were modified to better reflect the RFP’s intent. The EMS Ad Hoc committee and staff determined that adding more granular scoring elements will help the PRC to objectively and independently score proposals resulting in the best selection. The original score sheet contained broader categories, which have been broken into subcategories with more individually scored elements. The RFP now contains language directed to proposers, clarifying what materials should be provided to allow the PRC to successfully evaluate a proposer’s qualifications.
4) Addition of detailed guidance and instructions for the Proposal Review Committee. Staff added an overall vision and values statement to the RFP scoring section which includes language describing the policy goals of the EMS Ad Hoc committee such as the importance of considering innovation and community benefit when evaluating proposals. The RFP awards points for innovative programs and supplemental specialty training.
5) Equitable entry and scoring requirements for all proposers. The draft RFP rejected by the EMSA allowed different bonding, insurance and fiscal auditing practices based on a proposers organizational structure as a public or private entity. Staff have modified the elements identified by EMSA and have established consistent standards for all proposers. Staff and the Ad Hoc committee have determined that the minimum requirements meet the threshold for competence, establish a level baseline for competition, and allow the widest possible vendor engagement without taking on undue financial risk.
6) RFP Process Review: RFP processes were reviewed for conformance with Sonoma County procurement policies. Minor revisions were made to ensure alignment.
On November 2, 2021, CVEMSA submitted the revised RFP to the Board of Supervisors, including California EMSA recommendations and earlier Board direction incorporated. The Board directed CVEMSA to publicly announce the RFP and solicit proposals for service consistent with the County’s purchasing policies. The RFP was publicly posted on November 8, 2021 with a proposal due date of March 1, 2022. Concurrently, the Board directed CVEMSA to submit the RFP to California EMSA for final approval.
Conducting the RFP
On November 8, 2021, CVEMSA staff released the RFP to the public consistent with the County’s purchasing policies. The proposal due date was March 1, 2022. On December 2, 2021, County staff hosted a mandatory proposer’s pre-bid conference, the purpose of which was to answer questions that proposers may have about the RFP process and timeline. At that conference, attended by six potential proposers, the County received nearly universal feedback about the very challenging timeline between contract award and start of service. The primary concerns expressed were the challenges with equipment procurement given the growing global supply-chain crisis, the competitive labor market for medical professionals, and the challenge of transitioning during the current declared COVID emergency. Staff noted these concerns and committed to monitoring their potential impact over the next several weeks.
Through the Fall and Winter of 2021 and 2022, supply chain problems in the durable medical equipment sector, and particularly in the ambulance chassis industry, continued to escalate. In addition, availability of skilled medical personnel to staff ambulance service continued to worsen. As a result of these challenges, County staff determined that continuing with the current RFP timeline would result in significant risk of disruption to the ground ambulance system of care in Sonoma County.
Nexus to Settlement Agreement with Sonoma County Fire District (SCFD) and CalChiefs
In 2021, a dispute developed between SCFD and CalChiefs on the one hand and County on the other hand as to the County’s ability to create an exclusive operating area within the historic service area of Bell’s Healdsburg Ambulance Service, Inc. In an effort to settle that dispute and litigation, the County and the petitioners entered into a settlement agreement that was executed on February 17, 2022. The County’s agreement with SCFD and CalChiefs acknowledged the mutual interest in rescinding the RFP and reissuing it at a later date. The parties also agreed to an extension of the contract with the existing EOA-1 ground ambulance provider, American Medical Response, Inc., through January 15, 2024.
Rescission of the RFP, Stakeholder Engagement, and Plan to Reissue in Summer 2022
As a result of the market conditions, and consistent with the agreement with SCFD and CalChiefs, the County decided to rescind the RFP on February 18, 2022. CVEMSA has developed a draft timeline to administer the RFP with an extended implementation period in the event that market conditions do not improve. In an effort to continue stakeholder engagement, CVEMSA conducted two public meetings, one on April 15, 2022, and another on June 23, 2022, to gather feedback from stakeholders on the updated draft. The draft incorporates 42 of the 77 identified recommendations received by stakeholders. The draft before your Board includes track changes showing all revisions to the RFP since the November 2, 2021 Board approval including: 1) California EMSA recommendations; 2) CVEMSA staff recommendations: and, 3) adopted recommendations from the stakeholder feedback sessions.
With approval from your Board, CVEMSA will submit the RFP to California EMSA for final approval. CVEMSA will submit to the state both a track-change version showing the edits to the RFP since EMSA approval in February 2022, as well as a clean version of the Board-approved RFP. Staff believe the policy direction of the Board has been followed to ensure a fair and transparent process while conducting an RFP with the goal of procuring a highly qualified vendor from the widest possible group of proposers capable of serving the community. Staff also believes that the proposed RFP should receive state approval because minimal changes were made since the California EMSA last approved the RFP on February 8, 2022.
The RFP will be reissued shortly after California EMSA approval. Upon approval by California EMSA, staff will finalize the RFP timeline. The current tentative timeline is for the RFP to be published in September, proposal submittal in January/February 2023, approval by the Board of Supervisors in March/April 2023, and service beginning in January of 2024. This timeline will provide nearly 18 months for the RFP process and will ensure that the successful proposer will have ample time to implement service on January 16, 2024.
Proposal Review Procedure
The County will establish a non-biased Proposal Review Committee (PRC) consistent with Sonoma County Code Sec. 28-17. After the proposals are received by the County, each member of the PRC will evaluate and score the proposals based on the criteria specified in the solicitation. The scores from all the evaluators will be averaged to arrive at a final score for each proposal. All Proposals will be evaluated and scored by the PRC and be invited to participate in an oral presentation of their proposal. The committee will recommend the highest scoring Proposer for final negotiation of contract terms.
Following the competitive process, the Department Director will submit a written report including a recommendation to the Board of Supervisors who will approve or disapprove any proposed contract with the winning bidder. A copy of all proposals shall be kept on file with the Clerk of the Board and will be available through the Department of Health Services as public records.
RFP Timeline
The table below reflects the estimated RFP timeline and will be updated prior to RFP release.
|
Event |
Date |
Time |
|
RFP Document Available |
September 2, 2022 (Estimate) |
N/A |
|
Proposer’s Notice of Intent to Respond |
September 30, 2022 (Estimate) |
5:00 PM |
|
Proposer’s Written Questions Due |
September 30, 2022 (Estimate) |
5:00 PM |
|
County’s Responses to Questions Due |
October 14, 2022 (Estimate) |
N/A |
|
Mandatory Proposer’s Pre-Bid Conference |
Late October, 2022 (Estimate) |
10:00 AM |
|
Proposals Due |
February 3, 2023 (Estimate) |
10:00 AM |
|
Proposal Review |
Early February, 2023 (Estimate) |
|
|
Oral Presentations |
Early February, 2023 (Estimate) |
|
|
Notice of Intent to Award |
February, 2023 (Estimate) |
|
|
Contract Approval and Award - Board Meeting |
April, 2023 (Estimate) |
|
|
Implementation of Service |
January 16, 2024 |
00:01 AM |
Strategic Plan:
N/A
Prior Board Actions:
On November 2, 2021 the Board approved the RFP with the following direction: A) Approve the revisions to the Request for Proposal (RFP) approved by the Board on April 13, 2021. B) Authorize the Director to resubmit the RFP to California EMSA. C) Authorize the Director to make minor modifications prior to RFP release for non-substantive changes. D) Authorize the Director the RFP for responses.
On April 13, 2021 the Board A) reviewed the Matrix of Public Comments and Staff responses and Recommendations; B) approved changes to be incorporated into the RFP; and C) approved the RFP for submission to California Emergency Medical Services Authority (EMSA).
On March 23, 2021 the Board deliberated on the proposed components of the draft RFP for Exclusive Operating Area #1 (EOA 1) for the purposes of submitting the RFP to the California EMS Authority for approval based on the provision of Sonoma County Code Chapter 28-17, adopted by the Board on November 12, 2019.
On October 22, 2019 the Board approved an agreement with Endpoint EMS Consulting, LLC for subject matter expertise and support in developing a request for proposals for an exclusive provider of emergency ground ambulance services in an amount not-to-exceed $161,000 through December 31, 2021.
On May 21, 2019 the Board approved the third amendment to an agreement with American Medical Response West for emergency ground ambulance services, providing for an extension of the term through June 30, 2022 with an additional two one-year options and authorizing service rate increases effective July 1, 2019.
On May 8, 2018 the Board authorized the Chair to submit a letter expressing County support for a one-year extension request of the California Emergency Medical Services Authority for the Exclusive Operating Area Ambulance Services Agreement covering central Sonoma County and work with the area's Assembly members and State Senator to support this request.
On December 16, 2008 the Board approved the Emergency Ground Ambulance Services Agreement with American Medical Response West.
Fiscal Summary
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Expenditures |
FY 22-23 Adopted |
FY 23-24 Projected |
FY 24-25 Projected |
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Budgeted Expenses |
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Additional Appropriation Requested |
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Total Expenditures |
0 |
0 |
0 |
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Funding Sources |
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General Fund/WA GF |
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State/Federal |
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Fees/Other |
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Use of Fund Balance |
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Contingencies |
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Total Sources |
0 |
0 |
0 |
Narrative Explanation of Fiscal Impacts:
There are no fiscal impacts directly associated with this item.
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Staffing Impacts: |
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Position Title (Payroll Classification) |
Monthly Salary Range (A-I Step) |
Additions (Number) |
Deletions (Number) |
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Narrative Explanation of Staffing Impacts (If Required):
N/A
Attachments:
Attachment 1 - Draft Request for Proposals (Clean)
Attachment 2 - Draft Request for Proposals with Track-Change Revisions
Related Items “On File” with the Clerk of the Board:
None