Maine Islands Coalition Minutes August 10, 2007

Attendance:
Pete Anderson, Islesboro Rep.
David Jermann, North Haven Rep.
Betsy Weber, Great Diamond Rep.
Margaret Blank, Cranberry Isles EMS
Donna Damon, Chebeague Island Rep.
Roger Berle, Cliff Island, Chair of Islands Coalition
Eva Murray, Matinicus Rep.
Malcolm Donald, Cranberry Isles Rep.
Mark Tierney, Little Diamond Island Rep.
Mark Greene, Long Island Rep.
Sharon Daley, Maine Seacoast Mission Nurse
Donna Wiegle, Swan's Island Rep. (alt)
Sen. Ethan Strimling, Portland
Rep. Jonathan McKane, District 51
Chris Hamilton, Life Flight Director
David Crowley, Chief, Cliff Island Fire and Rescue
Tammy Brown, North Haven EMS
John Dietter, Crew Chief, North Haven EMS
Burke Lynch, Service Director, Vinalhaven Ambulance
Jay Bradshaw, Maine EMS Director
Chris McCarthy, Maine Quality Forum
Tom Judge, Executive Director of Life Flight
Eric Waters, Vice President; Support Services, Penobscot Bay Medical Center
Pommy Hatfield, Island Commons Resource Center
Kelly Rich, Executive Director Islands Commons Resource Center
Rudy Graf, Isle au Haut Rep.
Jen Litteral, Marine Programs Officer

I. Introductions by Roger Berle.

II. Health Care Panel: Issues of Emergency Services Perceived by Panelists
Dave Crowley, Head of Fire and Rescue on Cliff for 15 years.Noticed a concerning trend that ‘a large number of people are moving to the
island to die.' Hearing people saying that they ‘want to be here when they take their last breath,' and with the aging population it brings a required set of needs and services. This extra responsibility, plus doing everyday occurrences, means that it is very difficult to provide services. There is a need to produce good healthcare in the geriatric field. They are also losing 2 out of 3 of the EMTs, but 99% of the calls are for First
Responders, and there are a lot of those. Have been lucky that there are programs available for training and equipment.

Burke Lynch, Service Director Vinalhaven Ambulance
Education or basic training for EMTs:
Got tired of begging instructors to come to the island, so got his instructor coordinator certification and got a Basic class last summer. Problem comes with the intermediate and advanced training: have to commute to get skills, training, experience, etc.

Longer than usual transport times:
Overcoming logistics for ferry or a foggy day for a plane. Patients are uncomfortable on a long board, using CVAs. What about stroke victims? Have raised the possibility of getting a boat for the Fire and Rescue, but it would be very expensive. Need a climate
controlled, protected, medical service room.
Previous Medical Center Director lost support of fishing boats.

Administrative paperwork:
"Discouraging;" transfer of care, and then back to logistics of a flight off, which requires a ton of paperwork...all this makes crew retention difficult.

Other Retention Issues:
Lack of many healthcare providers - basically a doctor and nurse practitioner, on-call at night. At 2am they get non-emergency calls and this affects the quality of healthcare. Availability of off-island transport - "on call system for fishermen."

Tom Judge, Port Clyde, Executive Director of Life Flight
Life Flight:
Now the transporting service for Monhegan Rescue as well as the primary coverage for 60 islands in St. George Bay. Monhegan EMS collapsed, and Life Flight sees this as a very big issue. The logistics of managing a boat has been an issue for islands; a lot of
fishermen are willing to do this if they know the patient, but liability is a huge issue, so Life Flight sees itself as filling an important role. Life Flight is a non-profit owned by the medical companies in Maine; two helicopters, emergency department in the air. Envisioned the helicopters as public health issue.

Island Challenges:
For emergencies, islands present big challenges, primarily due to weather. Have worked hard to build reliability and safety into the system. Set up approaches to most of the islands to improve the availability of the services, and gotten helipads on hospitals. Also
do a lot of training and education; simulation lab that they can bring to the island. ‘An emergency service, treat everybody regardless of insurance - 28% of people have no insurance, and it's becoming more of an issue. 12% of operating budget was designated
for ‘charity cases.' Higher costs of a system for smaller populations. Young and people who are self-employed are the people who are leaving the healthcare system because they cannot pay for insurance. Infrastructure project just got an award.

Jay Bradshaw, Director of Maine EMS
Wanted to listen to hear about the needs of the islands. Maine EMS brings a significant resource to the table, and some things can be corrected easily, some may require legislative changes. Lots of challenges are identical to challenges on the mainland - recruitment, getting people to call 9-1-1.

Margaret Blank, Cranberry Isles EMS
Three years ago Islesford had nothing, thanks to Long Island we have an ambulance. Now the service will include Great Cranberry, Sutton, Bear and Baker Islands. Talked about having a boat, have never had problems with transporting patients, but will be an
issue as the responsibilities increase.

Comments/ Questions / Discussion:
John McCain - Monhegan is a scary situation and it seems the lesson to be learned is that it takes a large amount of time to be the EMS service provider. What can be done legislatively?

LD 977 A bill to study EMS services - will be DHS led, funded by Maine Health Association.

Jay Bradshaw - continuation of care - passing off patients to different groups; "it would help us to not go with the patient, it just takes a lot of time. It's sorting out who needs emergency care vs. who needs general care. Not every call in
Rockland goes with lights and sirens."

Sharon Daley - Monhegan had a land-based telemedicine unit that connected them with area physicians. It was only used twice, but it has potential to help.

McCain - transportation needs on each island is also very different.

Ethan Strimling - the task force was issued a few years ago on Homeland Security needs, Do people feel like the islands are prepared for a major disaster? Also, how does the Coast Guard get involved?

Bradshaw - When the issue of Monhegan arose, they were told that the Coast Guard was very hard to activate. Have worked on streamlining this. Coast Guard is willing to go, but they are probably your last hope. The Coast Guard is not willing to go out for somebody with a sprained ankle.

Tom Judge - DHS money hardly ever goes to EMS.

Eva Murray - if there was a crisis on Matinicus, evacuation is not the priority. We know how to wing-it on the islands, which makes us better to adapt to things. What we need is more people who are First Responders; critical care gets a lot of attention and money and it's helpful, but not as important as the first responders. Can DHS finance this? Regarding Coast Guard; more maritime rescue has been
accomplished by fishermen than the Coast Guard.

Strimling - DHS includes emergency response.

Judge - there is no money available for EMS on the Federal level. State, yes.

Bradshaw - but the money is competing with the city of Bangor and Portland's needs. A bill has been authorized to provide Federal EMS funding, but has never been funded.

John Dietter - just ran a 1st responder class, previously ran EMT classes. Very few of the people stayed on the squad because they were not getting enough calls to practice skills, but dealt with the paperwork. Decided to run 1st responder to get people experience, and then do a bridge EMT course. Also have several WFR certified, which expands their scope, but when the planes are flying they are not WFR certified. 2006 calls - 40 calls, 27 by Pen Air, 7 by ferry,

Tammy Brown - because of fed regulations a ferry that runs at midnight, they can't run in the morning. Depends on the captain, Coast Guard safety issue and DOT piloting regulations concerning length of time on the water. How do we get more people on the islands who are trainers? Seems like some money should be dedicated to this... Anyway to streamline paperwork? Answering questions again and again. Transfer of
information is bad. Paperwork reduction is huge.

Anderson - all islands are different. Very well covered on medical, but lacking on ambulance personnel. Transportation is really killing them. Ferry shutting down for trips in the morning. Lobster boats are concerned about the liability.

Blank - Sutton Island is a summer island that is a problem for Cranberry Isles EMS. Fire Chief doesn't want to cover island; there is definitely an issue because there are no roads or cars but we want to go over there.

III. Healthcare: Preventative and Continuing Care Issues Presented by Panelists
Sharon Daley, Nurse, Maine Seacoast Mission
Sees that hands-on experience is lacking for EMTs: knows procedures that EMTs are allowed to do in other rural areas that may be addressed and brought to Maine: systems in Alaska called Healthaids, for example.

Adaptive programming:
As a nurse, wants to do a lot of preventative care. A lot of agencies want to provide care, especially specialized care, but they don't have connections to people on the islands. Home-health agencies are also reluctant to provide services because they cannot use the
same programs that they would use on the mainland, so Sharon has been working with them to adapt and provide hospice care. Another major problem is families moving off and leaving elderly on the islands and then it goes to the town to take care of them.
Pommy Hatfield, Island Commons, Chebeague Island Wanted to provide a way for people who wanted to die on the island, stay on the island.
Out of this arose a care for assisted living care. One concerns is how to help people take care of elderly people in their homes. Still have transportation problems when services are paid by Medicare or Medicaid and private out of pocket expenses are cost-prohibitive
on many ways: parking, ferry costs, etc. Want to educate mainland providers, and help them educate providers to get people educated on how best to help elderly stay out of critical care.

Kelly Rich, Island Commons
one of the challenges of running the Commons is recruitment and training of staff, retention of providers, also regulations and paperwork.

Eric Waters, VP Operations at Pen Bay Medical Center
Came to hear issues, and hearing that finding, retaining and then get training people is a major concern. Would specifically like to figure out ways that they can help with the training. Will meet with the executive team to discuss this meeting and try and find solutions.

Chris McCarthy, Maine Quality Forum, "token social scientist!"
Personal background in community psychology and community development.

Maine Quality Forum healthcare:
A little known arm of Dirigo Health, with core mandates of promoting best practice and assessing the needs of healthcare in the State, charged with learning who's getting care, what they need, etc. Originally focused on hospital care, but now working on
standardizing best practices in care: working on getting people to care, at the right time and with the right services. Review certificate of need applications for quality issues. Wrote and participated in a Johnson grant for working on a chronic care model for people
in Maine. Would love to have some islanders involved to understand and interact with care providers.

Reactions:
Important to think of healthcare as a subset of health, and community services are also a subset. Wonders what already exists and how you can use it. Struck by the emphasis on professional care, when it is not usually professionals who are providing care. Emphasis
on prevention, chronic care management: diabetes, cardio-vascular disease, nonemergency acute care (sprained ankles, etc.). Maximize the use of non-professional models for health care. This is a similar conversation that many rural towns are having. One of our best roles is to convene groups. If this issue needs to be convened, then the Quality Forum is a way to do this.

Maine Quality Forum Ideas to Consider:

• Electronic technology is a tool, not an end-option, but a helpful tool and there may be options to expand this.
• Maybe 1st responder course becomes part of the Health requirement in school?
• Health-coach model - can engage with people, there are people who are seen ashealth coaches who can respond to non-emergent health issues.

Questions / Comments / Discussions:
Eva Murray - communities used to always have a "health-coach," but we are in such a litigious society that you need to have professional care for every sniffle. Maybe what we need to do is expand Good Samaritan Laws. We need to have communities that are acting as communities. There are several models for communities to do this, and they are generally more effective in insular communities.

Donna Damon - when my child was young, she had lots of ear infections and the island council bought an ear thing, onoscope, and they would ask Donna whether it looked like an ear infection, and they would describe it to the pharmacist and they would write a prescription.

McCarthy - Doctors can now electronically release "vending machines' of medicine. Can you access a hospital by boat? No, technically not.

Roger Berle - How can we access what you have offered, specifically in terms of training?

Waters - not a clinician, but can get you in contact with people to contact.

Judge - on board of Pen Bay, and chair the Community relations committee, but with both of us here we can carry these conversations forward.

Actions Steps:
1. Convene a discussion on "Unique Care-models." If we are doing things about non-professional services,
2. get more opportunities to hear the issues that are unique to health and healthcare on the islands.

Berle - Almost all of these islands have doctors there for the summers. Is there any difference between town First Responders or visiting doctors, I've heard that Doctors are not supposed to be the first point of contact, is that correct?

Daley - responding to a call for help is what people do, don't know if it's appropriate.

Bradshaw - it's often difficult legally for nurses, but physicians can respond. However, many doctors are great in a clinical situation at a hospital, but not good at emergency response.

Rudy Graf - IAH has a lot of summer doctors and a Mass General Doctor has treated many fishermen. Where can you get funding for education for EMTs? McClane Scholarship Jonathan Busko is a doctor who is looking on how to do classes remotely using technology. Bingham program.

End for Lunch

John McCain - there are a lot of issues, especially connected to the emergency part of island healthcare particularly:

• transportation - can we relax regulations about ferry travel.
• Influx of older folks coming back to the islands creating more healthcare needs.
• Overuse of ems
• Training people
• Temporary clinics, as mentioned by Tom Judge
• LD 977 - study of EMS on Maine to make sure that they are addressing
• Liability and immunity - looking at Good Samaritan Law.

Can we come up with very specific ideas that we would like to address in legislation?
Perhaps the title of a bill to address some of these issues and at least draw attention to the issues that we heard today.

Roger Berle - perhaps reconvening this group to focus upon the emergency care aspect that we discussed earlier this morning. Best thing that we can do is take action at these issues.

Tom Judge - look at this idea of an "unlicensed professional" Glad to have Chris McCarthy here, as a convening organization, they have a lot of authority.

Tammy - we really need to have some tips on educating health care providers about island issues, so that they are aware of the different needs of islanders.

IV. November Ballot Question Endorsment:
Jen Litteral, Island Institute Marine Programs Officer
We just completed a study and realized there really is only 20 miles of Working Waterfront left in Maine. A $2 million bond was awarded last year for Working Waterfront Access. Had over 200 inquiries, and we've given out money for 7 projects, one of which, the Port Clyde Co-op expansion, was one of 81 spots identified by Shey as having a perfect spot for fishing. Have expended all of the funds other than $100,000. Now, we are looking to expand the project with $3 million dollars for next year. We will be running a campaign with a bunch of different groups, under one question on the ballot. Do you favor a $35,500,000 bond issue to invest in land conservation, water access, wildlife habitat, outdoor recreation opportunities, including hunting and fishing, farmland and working waterfront and to invest in state parks, historic sites and riverfront, community and farm infrastructure to be matched by at least $21,875,000 in private and public contributions?

Mark Tierney motions to support the ballot initiative.

Donna Damon seconds

All in favor.

V. Tree Growth Discussion Continues:
Jeff Kendall, Maine Revenue Service
Recap from previous meeting - the islands represent a small part of the larger Tree Growth program, and Jeff was pushing towards going to the Forest Service to change things, rather than legislatively, because it is really working for 85% of the State. MRS feels that the law has been changed several times and it is unlikely to be changed again. Certainly aware that Tree Growth doesn't work on the islands in practice and in theory.

Morten Moesswilde, District Forester for the Mid Coast Region
Has dealt with Tree Growth primarily through questions from landowners and assessors. Moesswilde is one of 10 Foresters for the State, 3 of whom include Coastal areas. 90-95% of time is spent educating. Not a Forest Ranger, NOT law enforcement.

Three entities in Tree Growth:

• Maine Revenue
• Town Property Assessors
• Maine Forest Service - education and information for landowners. Statute for Tree Growth does not give the any authority to regulate or to amend rules. Also don't have the power to act on individual parts of Tree Growth.

Two areas where MFS can act:

• Review a management plan to see whether it fills the requirements
• Review an activity that is occurring on a property, and make a recommendation as to whether that activity confirms with what the management plan says.

As a general observation and from his experience, a lot of the phone calls that come into Augusta are in reference to Tree Growth, it is one of the most poorly understood programs among the general public. A lot of misconceptions. Has a 90 minute presentations that outlines just the basic aspects of the program.

Questions / Comments / Discussions:
Roger Berle - 65 acres, a large amount of land on Cliff, is in Tree Growth, which Cliff islanders and Portland love. But if they were to secede, then they would have a lot of revenue missing. Maintaining open space is critical to the character of the islands. Are there common questions about Tree Growth that you could answer?

Moesswilde - qualification is sues and how to go about getting tree growth status. Also, what harvesting do I want/need to do, how does that interact with a consulting forester. Any time you do anything in terms of forest management, you have to think in terms of decades and people don't think that far ahead.

Berle - there were major blowdowns from the Patriot's day storm - where's the intersection between cleaning up the forest from fire danger and tree growth?

Moesswilde - many questions arise concerning commercial value of timber, economics of doing clean-up, will the management plan need to be changed. There's a lot of lack of specificity in the Tree Growth Statute, as it depends upon
the forester's judgement.

Rudy Graf - where is the point where there is some enforcement of the plan? Is there any
oversight?

Moesswilde - MFS has no enforcement oversight, and with only 10 foresters, wouldn't be in any position to do that. So the oversight has to go to the plan. If they have a question, they would go.

David Jermann - The decision to qualify is based on the individual assessor. Is that
right?

Kendall - if you qualify, you're in. If the assessor says no, the State Board of Property Review can view an appeal.

Jermann - it sounds like a beareaucratic mess, is there any way to just scrap it?

McCain - anything is possible. You thought that it would be impossible to change for the islands.

Kendall - not likely, and this is where the spirit of the law breaks down. Maybe land on the islands belongs in open space rather than Tree Growth, less of a deduction fiscally. Conversely, the penalty if a property is removed from tree growth is greater.

Moesswilde - 17 million acres of forestland in Maine, 6 million is owned by landowners who own less than 1,000 acres each. Of these, roughly 2-2.5 million acres is in Tree Growth. I have none of the industrial ownerships. Some of these folks have backland in Tree Growth, some have lakefront. The spectrum is very broad in terms of Forest quality and lands in Tree Growth.

Damon- the Tree Growth plan must be confidential, why, when our assessments are all public? I'm a town official, and it sounds that we wouldn't be able to tell anybody what we found when we looked at the plan. Also, what is the rationale for this?

Moesswilde - the analogy that comes to mind, you can tell what's in your house, but not show your blueprints. A forest management plan with property in Tree Growth could have all kinds of information: appraisal of timber, documentation of historic sites, etc. It can document what could be a very valuable asset.

Damon - but they are getting serious benefit. It's just surprising. Is there a way to have the basic plan without some of the personal information so that the general public who either gets benefit or loses tax revenue should be able to know what's going on?

Moesswilde - there have been towns and foresters and landowners who give the plans to the town, and some have been contacted by loggers who want their wood.

Damon - this is something that the legislature could change the rules to make this more public.

Kendall - these things are proprietary also because commercial woodlots are competing with each other. If two woodlots knew when people were going to cut, then they could fllod the market.

Damon - but this is apples and oranges, commercial forestry vs. people seeking a tax dodge. There could be a second tier- for landowners who sell less than a certain amount of wood, there would be a different criteria. It shouldn't be cut and dry.

Kendall - definition of commercial use could be tightened up, forestry and management plan is for regeneration of timber, and since these are not being done on stands on the island, perhaps these need to be tightened up. I don't think the laws going away, but there must be a way to tighten the regulations of the law. Your efforts would be rewarded more rapidly than if you were to try and change the law. In the Tree Growth discussion, you're a small segment of the population.

Chris Anderson - worked for MCHT as a lobbyist and public policy program. Used to lobby a lot saying this program works, basically, and don't tinker with it. All of the forestry industry, conservation community, etc. would line up and the support the revenue sharing situation. All of them also agreed that the State should fully reimburse the towns as promised. On the islands, they found that the penalties to take the land out of the program were too weak to prevent the land from being removed from classification. From the town's point of view, increase the penalties to get people not to put it in Tree Growth. From the conservation standpoint, it's a stop-gap measure, maybe they'll put it in Tree Growth now, and in permanent conservation later. So we liked people to put land in tree growth, protected it and helped retain the character of the town.

Pete Anderson - if one of the criteria was that it had to be done as a commercial operation, and if it is not being done commercially because it is cost-prohibitive on the islands, then that should mean that is doesn't qualify.

Kendall - commercial forestry can't compete with development anywhere across the state. But you can't discriminate when you apply a law.

Mark Tierney - at the last meeting, a property on North Haven was described that would as long as there was a certified stamp on the management plan by a certified forester, there was no way to reject that plan. Is that correct?

Moesswilde - well yes, but they are licensed forester and they are putting their license on the line.

Tierney - has there ever been a challenge to a person's license in your experience, is there an appeal process?

Moesswilde - I'm not aware of any in a tree growth situation, it's happened in other situations,

VI. Wildland Urban Interface Program
Kent Nelson, Fire Protection Specialist, Forest Protection Division, WUI Committee mostly working with the media and the process of administering the grant. Wildland Urban Interface - "where the homes meet the forest." Homes can be susceptible to forest fires, forests can be susceptible to structure fires. Began in Maine in 2003 with grants from the USFS, began working with Acadia to determine an assessment the risk for individual homes. First assessment in 2004 was of Peaks Island - have done follow-up work, giving them a hazard mitigation plan that the town can voluntarily adopted.

In process of doing community assessments on the district level, it evolved into working with the Institute last fall, they pay about 1/5th of the cost of the Fellows Program to do these assessments. One requirement of the grant is to provide an educational component; they have scheduled a workshop at the Island Teachers Conference in October, it's a great opportunity to teach about fire ecology and fire. One
of the important things is to address what the homeowner can do to reduce their risk of fire danger.

The most important protective measure is to set up defensible or survivable space around your house. If we FS has a dense, wind-driven fire in a softwood forest, they will have to do triage and will choose which of the houses would be likely to survive, they don't have the resources to protect structures from fires.

Questions / Comments / Discussion
Damon - How does this all tie into the restrictive nature of Shoreland zoning to cut trees. Looking at these laws, we were shocked. All of these islands were once farmland and open, experiences have occurred where people were penalized for cutting trees on the
shoreland zone, and then it all got blown down in the Patriot's Day Storm.

Moesswilde - Rich Baker, Shoreland Zoning Coordinator, contact him. There is a provision for hazard trees, for how many trees you have, etc.

Mark Greene - Shoreland zoning is onerous at first, but works.

Graf - biggest problems are blowdowns, turning it into a tinderbox. Park does nothing, but even on private property, there is no focus on getting those cleaned up.

Kent - can't speak for the Park Service, but did work for them and went to IAH to cut a fire break. But understands, it's frustrating. We're trying to find a way to help islands to get better forests.

Eva Murray - Are your trainings open to civilians? We don't have the numbers or requirements for much firefighter training.

Alan Hammond - State Planning Office - assessments are important for this. A lot of fire departments have preplanning of how to fight fires and do preventative work. What we are doing is really similar; perhaps the assessments can lead to a plan that firefighting needs are requested. Individuals are allowed to attend the firefighter training academy in June, and they will lend out gear to provide you
with equipment.

Kent - we would definitely be willing to work with you.

Weber - you don't even know who is going to be on the island, so you never know who can fight fires or who can't fight fires, you're initial start to fighting the fire is impeded. That's why training for people who are maybe not officially firefighters is important. You ought to have a "fire 1st responder course."

Kent - if you can't send the whole department, then you should send one person that can then pass that information onto others. This is the way to get people trained.

VII. Next Meeting: Friday, November 9th
Adjourned at 2:18