Could More Regionalization Help Rural EMS Providers Survive?
A lot of rural EMS services are struggling these days, with reliance on volunteers who are becoming harder to recruit and retain. Over half of rural EMS agencies are staffed by volunteers, but the volunteer pool is shrinking nationally.1 Other rural challenges include: longer travel distances, closures of rural hospitals, burnout, inadequate reimbursement and lack of skill at maximizing billing opportunities, the need for more training and standardization, and reported longer call times and poorer outcomes for patients.
Some EMS experts suggest that pooling resources on a regionalized basis could help in managing the problems confronting rural EMS; it’s quickly becoming an essential survival strategy for many rural emergency services. When multiple small agencies in close proximity choose to collaborate, pool their resources, and plan sites and schedules based on need, they can regionalize their services to improve efficiency through centralized administration and dispatch while spreading expenses across a wider geography. Ambulances can still be localized within the service area based on need.
Regionalization also offers opportunities to strengthen the agency’s leadership and increase employment and career advancement opportunities—while preserving the safety net and ensuring that EMS assistance arrives in a timely manner regardless of where patients are located.
In Canada, these issues have been recognized since the 1990s and have been a target for strategies by the Canadian Association of Emergency Physicians (CAEP), among others, with the goal of facilitating emergency services while conserving human resources. But given political and logistical challenges, it never became a major solution to the problem of scant emergency services in rural communities, says Alan Drummond, MD, an emergency physician in Perth, Ontario, and CAEP’s past president.
“A number of reports in Ontario (and elsewhere) in the early 1990s called for the grouping of rural emergency departments within small geographic regions to facilitate emergency services while conserving human resources, but without great success,” Drummond said.
Statewide Regionalization Strategies
In Wyoming, Governor Mark Gorden attempted to push an EMS regionalization strategy, requesting funding to facilitate regional approaches. But it failed to advance in the legislature in 2023.2 Other states have also acknowledged the need to support their rural EMS. Earlier this year a bill was introduced in the North Dakota legislature to create the “Distressed Ambulance Service Program,” requiring the health department to collaborate with struggling EMS providers to help ensure their viability. Bolstering EMS would involve new state funding for equipment, training and support.
Idaho state Sen. Mark Harris is pushing legislation to alleviate the woes of that state’s often-struggling EMS units, most of which are staffed by volunteers, by establishing county-level coordinators, offering additional state funding, and moving EMS regulatory responsibility from the Department of Health & Welfare to the Idaho Military Division. In Minnesota, an alternative EMS response model pilot program aims to bolster rural EMS with a $30 million investment and establishment of a state Office of Emergency Medical Services.
When EMS was first implemented, it wasn’t intended to do all the things it does today, says Jen Davis, until recently a senior policy advisor for health and human services for Wyoming’s Gov. Gordon. “We didn’t account for that system to evolve as it has. Now we tend not to have the right infrastructure to support it, and we’re struggling with how to reframe what EMS does. The regionalization conversation is something the state of Wyoming has been interested in, but we haven’t made a ton of progress.”
This conversation is complicated by the fact that EMS as an industry is so diverse, Davis said. “There’s not one entity doing it. You have hospitals, fire departments and private companies. So, we’ve been thinking more about it from infrastructure and emergency response perspectives,” she said. “How do we get services on board to partner more effectively?”
At the same time, there are many challenges, starting with territoriality—which usually means somebody’s job might be in jeopardy. In some localities they don’t even have enough resources and capacity to participate in a conversation about whether regionalization would help, she said. “But if we want this system to sustain and accomplish what we’d like it to do, we need to consider that the role of EMS in rural communities means more than just going on runs.”
Collaboration Across Counties
Although Gov. Gordon was unsuccessful in pushing a more regionalized approach to rural EMS in Wyoming, a couple of localities, including one encompassing Sheridan, Campbell, and Weston Counties in the northeast corner of the state, have demonstrated the advantages of regionalization.
Shane Kirsch, manager of Campbell County Health EMS, has been spearheading the collaborative regionalization of EMS services across those three northeast counties based out of a program he describes as hospital-based and quasi-governmental. Today CCH-EMS employs 90 staff, including 42 paramedics, serving an area of 85,000 people across 10,000 square miles from four base locations operating eight ambulances 24/7. “In Northeast Wyoming, we’re used to long distances,” Kirsch said.
A process of culture change begun under previous EMS manager, Chris Beltz, has helped to open doors for reaching out to collaborate with nearby small, struggling volunteer EMS services. “Before 2021, we offered mutual aid and support,” Kirsch said. In that year, CCH was approached by a private service in Newcastle, whose owner wanted to retire. Whether or not that service closed, CCH-EMS would have felt an obligation to respond to emergency calls in its locality, Kirsch said. “So we were filling the gap.”
Incorporating this service into CCH-EMS sparked conversations with other EMS providers in the area, working with various collaborative and relational models based on need. Then an emergency room doctor at the community hospital in Sheridan called, seeking collaboration to support its EMS service. Other small communities with struggling EMS followed suit.
“We’ve become known as a resource, and that’s what I’d like us to be seen as,” Kirsch said. “My focus as manager is not hostile takeovers.” A more responsible approach is to help local EMS improve services, rather than just taking over.
“The concept of regionalization of EMS takes all the players—to address funding, staffing and everything in between,” Beltz said, who is currently director of urgent and emergent services for CCH. “Our approach is to collaborate with all the players—cities, counties, hospitals, etc. What do you need? How can we adapt?” There can be a hesitancy for small agencies to give up a piece of their identity, he said. “But the point I try to make is that they’ve got to recognize how essential EMS is for their community.”
A Hard Truth
For Tim Nowak, founder and CEO of the consulting firm Emergency Medical Solutions in Green Bay, Wisconsin, parochial attitudes and personal egotism may be standing in the way of the necessary changes for small rural EMS services to survive. “Agencies need to drop the egotism, so that functioning, paid, career-based services with stronger leadership can emerge, even in the most rural areas,” he said.
“Trying to keep volunteerism alive when it’s dying out while not addressing needs for funding and standards, we’re only hurting ourselves.” A lot of rural EMS services are struggling, trying to get by with bake sales, hoping that will make it work, he said. They miss the point: consolidating services doesn’t have to equate with losing services.
“You’re pooling your resources, with an identity for one agency, one name, one patch, one billing resource, while the service still exists in your local communities. But that fear that they’re losing control plagues the thought processes of a lot of rural administrators, hurting an entire industry,” he said.
“Based on what I’ve seen in my consulting work around the country, consolidation, mergers, and regionalization absolutely need to happen.” It’s not just an issue for the wide-open spaces of the West, or just for EMS, he said. For example, the tiny state of Connecticut has 169 municipalities and nearly 275 fire departments. “There’s no way to sugar-coat it,” Nowak said. We’ve missed the opportunity to make it easy. We’re at the point where either you do this or you’re posing risk for your system and your community.”
But unless they understand the full spectrum of how EMS is paid for, there just isn’t the appetite from legislative bodies to pay for it, Davis said. “They think it’s already covered—but it’s not, really.” Solutions need to start with sustainable funding and effective billing. “Then let’s see where the gaps are where regionalized services might help leverage resources in a more meaningful way?”
One of the biggest barriers to rationalized regionalization, Davis said, “the public doesn’t understand the system, either. They just expect the ambulance to show up when they call, but it’s not that simple. There’s a lack of knowledge about how the system works, even among some legislators. How can we make it whole?”
References
- “Rural EMS.” Fact Sheet from National Rural Health Association. https://www.ruralhealth.us/nationalruralhealth/media/documents/advocacy/advocacy%20leave-behinds%202024/rural-ems-priorities_1.pdf.
- Shelby Kruse. Gov. Gordon aims to continue regionalization of emergency medical service. Sheridan Press, September 6, 2023. https://www.thesheridanpress.com/news/local/gov-gordon-aims-to-continue-regionalization-of-emergency-medical-service/article_6d1f4fde-4cc2-11ee-a178-a30c60696491.html.
