Vision West July 18, 2013

1. Vision WestJuly 18, 2013 Division of EMS & Trauma ND Department of Health Tom Nehring

2. Reality • Division Director – Ambulance Services and Trauma • Given Advantages Because of Rural EMS Improvement Project and Very Active NDEMSA and OIEMS • Focused on Oil Impact Because of the Ever Changing Impact on Trauma and Ambulance Services • Healthcare Oil Impact Guru • Recognized Authority for Representing the Entire Continuum of Healthcare • Ahead of the Impact • Able to Give a Complete Picture in One Hour What I Am What I Am Not

3. BAKKEN ACTIVITY • 178 drilling rigs • 5,439 active wells • 359,589 barrels per day • 2,000 new wells to come on line in 2011 • 1,500- 1,900 new wells per year up to 21,250 wells (NDSU, 2010) • Possibly 50,000 new wells (Bismarck Tribune, 2010) • 189 drilling rigs • 8634 active wells • 24,267,186 in March • Almost 800,000 barrels per day • Possible peak of 2 – 3 billion per day • 1,500- 1,900 new wells per year up to 41,200 wells 2010 - 2011Estimates 2013 March Actual

4. Oil/Energy Impact in HealthcareJust keeping up!!! Issues • Boom has not peaked • Uncertain about size of future demand • Not confident about information • Current needs are greater than resources

5. Oil/Energy Impact a crisis within a crisiswith all the characteristics of a slow disaster, presenting dangers to patients, providers and the public.

6. Oil/Energy ImpactMagnitude • Populations growth • Housing • Traffic / roads • Public safety • The money

7. Oil/Energy Impact 7 Challenges • Increasing demand for service • Difficultly getting keeping staff • Where to live • Real and perceived safety issues • Funding issues • Lack of collaboration • Just keeping up

8. Oil/Energy Impact Getting and Keeping Staff • Some workers have left jobs for oil jobs • Long distance transport time difficult for volunteers • Difficult to compete with oil wages • Hiring nearly impossible • Housing shortage and cost of housing

9. Who Is Impacted • Entire continuum • Dispatchers • First Responders/QRU, Law Enforcement, Fire, etc. • Emergency Medical Services • Clinics • Physicians • CAH Hospitals • Tertiary Hospitals • Long Term Care Facilities • Public Health • Disaster Preparedness • Health Department • Other healthcare delivery entities • Patients

10. Size of Impact Area • Level 1 – Big four – Epicenter - Mountrail County, McKenzie County – Williams County – Dunn County • Level 2 – Divide County – Burke County – Billings County – Bottineau County – Bowman County –Stark County • All Others – Peripheral Impact • Based on Active Rigs and Oil Production • Production Tax

11. Ambulance Services • 17 original oil impacted counties • Recently added two more • 44 ambulance services within impacted area • 3 ambulance services that are full time • 41 ambulance services that are volunteer

12. EMS Volume Issues • Since 2006 • Non-oil agencies increased 5.37% • Oil related agencies increased 58.99% • Epicenter agencies increased as much as: • Watford City 628% • New Town 164% • Billings County 238% • Killdeer 257% • Dickinson 94%

13. Law Enforcement • Fatalities increasing dramatically 2 times last year • More domestic issues/violence • Large increase in motor vehicle accident • Greater acuity of those injured • Much more traffic • Unable to respond as 1st responders on EMS calls • Unavailable because of workload • Have had to provide housing or allowances • Workforce

14. Oil/Energy Impact • “This is crazy.” • “We’re overwhelmed.” • “You can’t assess this with the numbers. You have to see it.” • “It’s getting worse everyday.” • “We’re starting to understand big city EMS.” • “Some days its nonstop.” • “We’ve never been so busy.” • “We used to know our patients, now we don’t know anyone.” • “No need to turn on lights and sirens, no one pulls over.” • “You’ve got both hands gripping the wheel where ever you go – it’s exhausting.” • “They’re making new roads and wrecking roads faster than we can keep up.” • “We were having trouble keeping people before all this.” • “Who wants to volunteer to take care of people who are making thousands and don’t care you have to get up at night?” • “If we had money to hire people where would we put them?” (EMS leader/provider interviews)

15. Oil/Energy ImpactIncreasing Demand • NW Trauma region increase 108% from 2007 to 2011 • 2007 – 750 cases vs. 2011 – 1556 cases • Trinity In Minot increased in trauma 107% from 2007 to 2012 • 2007 – 490 cases vs. 1015 cases in 2012 • This is the busiest quadrant of the state for trauma • Trinity is the busiest hospital for trauma in North Dakota

16. Myth • Because of increased volume in healthcare everyone should be making more money • Cost/needs vs. revenue • Bad Debt vs. transient population (workers making increased money does not translate into less bad debt)

17. Hospitals – Survey by ND Hospital Association • Bad debt – more significant in oil impacted areas • Increase in ER visits • Turnover percentage • Open positions at year-end • Annual contract labor costs • Increased wages and benefits • Housing crisis

18. NDHA Top 3 Concerns • Growing bad debt • Workforce • Housing

19. Physicians & Other Providers • Large increase in volume • Much more time spent in ER • Recruitment and retention – communities not the same • Cannot offer appointments as in the past • Transfers – paperwork, notification, arranging details

20. Long Term Care • Suffers from the same issues as others • Contract staffing • Workforce issues • Housing • Older permanent population moving out of area

21. Oil/Energy Impact Funding Issues • Increased costs of response/readiness • Equipment • Vehicles • Workforce • Workforce housing • Training • No pays • Updating or building new facilities

22. Oil Impact Grants2012 Calendar Year • 3rd Cycle – Emergency Services – Starts in January • 44 Million dollar ask for 2 million dollar availability • Was increased to 12 million • Only included EMS, Law Enforcement, Fire • Did not include funding for staffing • Additional cycle started in August – 4 million available

23. Oil Impact Grant2013 Calendar Year • EMS – 7 million dollars • Starts in September • ? Staffing • Hospitals – low interest loan program – 40 million dollars – task force working on applications • Fire and Law Enforcement

24. Stop!! • Dividing into separate and distinct groups all asking from the same sources (funding) • Keeping challenges to your group • Ignoring the issues • Living in the present

25. Recommendations • Tell a uniform story over and over and over again to anyone who will listen • Promote collaboration and regional planning • Practice workforce planning • Define meaningful performance measures and collect appropriate data • Become familiar with real data and incorporate into the story • Temporary staffing relief

26. Recommendations (cont.) • Supplemental staffing grants • Equipment, vehicle, facility grants • Training for oil rig response and safety • Housing • Supplemental long-distance transfer resources • Reimbursement for no-pays • Informing politicians about what is going on

27. DEMST Website • nd.gov/health/ems

28. Questions?