Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule establishes training and transport
requirements for ground ambulances to transport patients to Missouri Department
of Mental Health designated behavioral health crisis centers and other
locations for those patients who do not require transport to a hospital and
whose health needs can be met by behavioral health crisis centers or these
other locations where patients are transported.
EMERGENCY STATEMENT: This emergency rule establishes
training and transport requirements for ground ambulances to transport patients
to Missouri Department of Mental Health designated behavioral health crisis
centers and other locations for those patients who do not require transport to
a hospital and whose health needs can be met by behavioral health crisis
centers or other locations where patients are transported. The Missouri
Department of Mental Health filed
9 CSR
30-7.010 on November 2, 2022, which created
regulations for behavioral health crisis centers. Regulation
9 CSR
30-7.010 became effective on June 30, 2023. The
purpose of these behavioral health crisis centers is to interrupt and/or
ameliorate a behavioral health crisis experience with the goal of symptom
reduction, observation, stabilization, and restoration to a previous level of
functioning for the individuals being served. Currently, there are eighteen
(18) behavioral health crisis centers located throughout Missouri with six (6)
planned expansion locations. These behavioral health crisis centers provide an
alternative location for emergency medical services "EMS" and law enforcement
to transport individuals experiencing a behavioral health crisis who do not
require hospitalization/a level of medical care that only hospitals can
provide. By transporting these individuals to behavioral health crisis centers,
these patients can receive individualized services to stabilize their immediate
crisis, which may include linking the individual to additional treatment
services, for further evaluation and/or to behavioral health services. EMS and
hospitals in Missouri are extremely busy and understaffed in many areas of
Missouri. This rule encourages EMS to consider alternative transport to
behavioral health crisis centers and other locations to provide more
individualized services for individuals seeking assistance by EMS who do not
require a hospital level of care and who can benefit from these individualized
services to meet their immediate crisis needs and a linkage to other services
for long-term treatment. This rule also provides a framework for EMS to follow
when considering transport to behavioral health crisis centers, so that EMS can
get reimbursed for transport to behavioral health crisis centers by Medicaid in
the future. This emergency rule is necessary to protect a compelling
governmental interest to reduce the repetitive calls to EMS that strain the
emergency system from individuals who do not necessarily require a hospital
level of care, but who require individualized services that behavioral health
crisis centers and other locations can better meet the individuals' immediate
and long-term needs and promote the individuals' health and well-being. As a
result, the Department of Health and Senior Services finds a compelling
governmental interest, which requires this emergency action. A proposed rule,
which covers the same material, is published in this issue of the Missouri
Register. The scope of this emergency rule is limited to the circumstances
creating the emergency and complies with the protections extended in the
Missouri and United States Constitutions. The Department of Health and Senior
Services believes this emergency rule is fair to all interested persons and
parties under the circumstances. This emergency rule was filed February 26,
2024, becomes effective March 11, 2024, and expires September 06,
2024.
(1) As used in this
rule, the following terms and phrases shall mean:
(A) Advanced emergency medical technician
(also known as Emergency Medical Technician-Intermediate) - the midlevel of
licensure of licensed emergency medical services' personnel who meet the
requirements of 19 CSR
30-40.342(5);
(B) Advanced life support shall mean an
advanced level of care as provided to the adult and pediatric patient when a
patient is in a more critical condition and a paramedic is required to assist
in the treatment of the patient during transport by an ambulance;
(C) Basic life support shall mean a basic
level of care, as provided to the adult and pediatric patient where only
emergency medical technicians are on ambulances during transport;
(D) BHCC shall mean Behavioral Health Crisis
Centers designated by the Missouri Department of Mental Health;
(E) Department shall mean the Missouri
Department of Health and Senior Services;
(F) Emergency Medical Technician means the
lowest level of licensure of licensed emergency medical services' personnel who
meet the requirements in
19 CSR
30-40.342(2);
(G) Ground ambulance services shall mean
ambulance services licensed under
19 CSR
30-40.309;
(H) Hospital shall mean the definition of
hospital in section 197.020, RSMo or a hospital
operated by the state of Missouri;
(I) Medical director shall mean the medical
director of an ambulance service as required by
19 CSR
30-40.303; and
(J) Paramedic means the highest level of
licensure of licensed emergency medical services' personnel who meet the
requirements in 19 CSR
30-40.342(4).
(2) Transport of patients to locations, which
are not hospitals, following a request for emergency care.
(A) Ground ambulance services may transport
patients to locations that are not hospitals, such as BHCCs in Missouri,
following a request for emergency care.
1.
Ground ambulance services shall have written transportation protocols that
allow ground ambulance services to transport to locations that are not
hospitals, such as BHCCs in Missouri; or
2. Licensed emergency medical services
personnel for ground ambulance services shall receive physician orders for
approval to transport patients to locations that are not hospitals, such as
BHCCs in Missouri.
3. Ground
ambulance services shall transport patients to hospitals if patients require a
level of care that only the hospitals can provide. This includes transporting
behavioral health patients to hospitals who present with a likelihood of
serious harm to themselves or others as the term "likelihood of serious harm"
is defined under section
632.005, RSMo, or who present as
significantly incapacitated by alcohol or drugs.
4. Ground ambulance services shall have a
working relationship with the BHCCs and other providers of locations that they
transport patients to that are not hospitals. Ground ambulance services shall
understand the care that BHCCs and these other providers are able to give to
patients, so patients are transported to an appropriate location in which the
provider can provide the services that the patients require.
5. Ground ambulance services shall not
transport patients to freestanding emergency departments unlicensed by the
department, which are separate from the main hospital, when the patients
require a hospital level of care, or when the patients do not require a
hospital level of care and require a lesser level of care. Patients shall be
transported to the emergency department located in the main hospital when the
patients require a hospital level of care.
6. Ground ambulance services shall transport
trauma, stroke and ST-elevation myocardial infarction (STEMI) patients to the
appropriate department designated trauma, stroke or STEMI centers as set forth
in the ground ambulance services' department approved community plan as allowed
in 19 CSR
30-40.770 or in accordance with the department's
transport protocols in
19 CSR
30-40.790 and
19 CSR
30-40.792.
(B) When providing services to patients
transported to locations that are not hospitals following a request for
emergency care, licensed emergency medical services personnel for ground
ambulance services shall follow written medical protocols, physician orders to
provide medical care, or orders from qualified health care professionals who
have collaborative practice arrangements with physicians and are allowed under
Missouri law and their collaborative practice arrangement to dispense or
prescribe drugs and provide treatment. Paramedics for the ground ambulance
services evaluating patients do not have to be on the ambulance crew that
transports patients. Paramedics for the ground ambulance services can arrive on
the scene to evaluate the patient and the patient may be transported to the
location, which is not a hospital, with a basic life support ambulance staffed
by emergency medical technicians and/or advanced emergency medical technicians
if the patient does not require advanced life support care. Patients shall be
transported by advanced life support ambulances or basic life support
ambulances based on the patients' care needs.
(C) Licensed ground ambulance service
personnel who evaluate and transport patients to facilities providing mental
health services that are not hospitals, such as BHCCs in Missouri, shall be
trained by the ground ambulance service or other providers on evaluating and
caring for patients with mental health concerns. This training may include
ground ambulance service personnel attending and completing the Missouri Crisis
Intervention Team forty (40) hour course discussed in section
190.147, RSMo.
(D) Written transportation and medical
protocols set forth in (2)(A) and (2)(B) shall be approved by the medical
director of the service.
(E) Ground
ambulance services shall conduct training and activities with the services'
personnel to ensure written transportation protocols and medical protocols set
forth in (2) (A) and (2)(B) are properly implemented and followed.
(F) Ground ambulance services shall evaluate
the written transportation and medical protocols set forth in (2)(A) and (2)
(B) to ensure the protocols are being properly implemented and followed by the
services' personnel during a review of these transports through the services'
quality improvement program.
