VOLUNTEER COMMUNITY ORGANIZATIONS
April 2006
This publication
was funded by the Health Resources and Services Administration's
Office of Rural Health Policy with the Frontier Education Center
under
Contract Number HHSH250200436014C.
TABLE
OF CONTENTS
Note on the Definition Of
Frontier
- BACKGROUND
- Brief History of EMS
- Models of EMS Service
Provision
- CHALLENGES FACING
VOLUNTEER EMS STAFFING
- Volunteer Availability
- Aging Volunteer Workforce
- Impacts of National
Standards and Testing
- Challenges at the Primary
Workplace
- Maintaining Skills in
Low Volume Services
- EXAMPLES OF PAID AND
VOLUNTEER EMS PROGRAMS
- State Programs
- High Percentage of
"Paid" Workers
Missouri
Tennessee
- High Percentage of
Volunteers
Nebraska
Wisconsin
- Local Programs
- Paid and Volunteers:
Two Communities, Shared Management
Madawaska, Maine
Fort Kent, Maine
- Kansas Frontier Experience
Greeley County, Kansas
Sheridan County, Kansas
- Innovative Approaches
to Maintaining Frontier EMS
- Owyhee Community Health
Facility, Nevada
- Margaretville Memorial
Hospital, New York
- Utah Criminal Fine
Revenue
- Issues Related to Billing
and Collections
- SUMMARY
- REFERENCES
Appendix A: Frontier
and Rural Expert Panel
Appendix B: Contact List
Appendix C: Frontier
Education Center EMS Information Request, April 2005:
Response Summaries
DEFINITION OF FRONTIER
All references to "frontier" use the
Consensus
Definition of the Frontier Education Center unless otherwise
indicated. Counties and/or frontier areas so defined have been developed
with the involvement of all of the relevant State Offices of Rural
Health (100 percent response rate). This definition has not been
adopted by any Federal programs but has been adopted as policy by
the Western
Governors' Association and the National Rural Health Association.
The Consensus Definition weights three elements - population density,
distance in miles and travel time in minutes - which together, generally
describe the geographic isolation of frontier communities from market
and/or service centers. The Center understands that various programs
will establish their own programmatic definitions and eligibility
criteria.
Emergency Medical Services in Frontier Areas:
Volunteer Community Organizations
I. BACKGROUND
The purpose of this paper is to provide information
on paid and volunteer Emergency Medical Services (EMS) workers in
frontier and rural areas. This is not a formal research paper, but
a presentation of an information-gathering project and a fact checking
of anecdotes.
Frontier and Rural Expert Panel. A panel of frontier
and rural leaders from varied backgrounds met on April 14, 2005
to discuss several issues facing frontier and rural communities.
The members of the panel are listed in Appendix A. Pertinent to
this paper, a discussion was held on the broad topic 'Volunteer
and Paid Emergency Medical Services in Frontier and Rural Areas.'
In preparation for the meeting, readily available information was
gathered to supplement the panel discussion. An Internet literature
search for information on paid and volunteer EMS workers in frontier
and rural areas was conducted. Because only limited information
was available from any single source, multiple data sources were
combined.
Information from State EMS Offices. Using the
directory of the National Association of EMS Directors (NAEMSD),
each State EMS office was contacted by email and/or telephone. Appendix
C presents a compilation of State responses. Where possible, these
data were supplemented by other data available online, including
a 2003 survey conducted by the National EMSC (EMS for Children)
Data Analysis Resource Center (NEDARC). It became clear that there
is no uniform EMS data collection among the States. Some States
collect information about paid or volunteer workers; others do not.
Among those that do, only a few of those report rural or frontier
services separately. Therefore, outreach was made directly to the
field to clarify or expand upon the information available to the
public and gathered for the Expert Panel.
Unsurprisingly, the view from the grassroots is
often quite different from the data presented by various agencies.
Complicating the entire project is the absolute lack of a consistent
definition of the word "volunteer."
A. Brief History of Modern EMS
Prior to the development of modern EMS in the
1960s, only a few hospitals in large cities provided ambulance service.
In most communities, a trip to the hospital was provided by friends
and family or by the funeral home. In the late 1950s, as more Americans
became car owners and driving a car replaced other forms of transportation,
more people were subsequently injured and killed in crashes. The
first rescue squads began to emerge and they were primarily volunteer
(Nelsen & Barley 1997). According to Nelsen & Barley (1997),
"The EMT's work emerged out of a series of social movements
that first made a national priority and then a medical issue of
what was initially a logistical problem: how to transport injured
motorists to hospitals" (p. 627).
The modern era of EMS began after the 1966 publication
by the National Academy of Sciences, National Research Council paper
"Accidental Death and Disability: the Neglected Disease of
Modern Society" (McGinnis 2004). Improved equipment and advanced
training for medics during the Viet Nam War led to numerous advances
in emergency medicine. These new skills and equipment were soon
put to use at home. The National Highway Safety Act of 1966 was
the first Federal legislation requiring States to develop systems
to rescue injured motorists. Most States provided these services
by organizing and equipping volunteer rescue services. The Federal
Emergency Medical Services Systems Act of 1973 established the first
national standards for training and equipment.
In many communities, EMS is provided as a public
safety function supported by the National Highway Transportation
Safety Administration (NHTSA) as well as State and local governments.
In other communities EMS is considered a health service with State
and/or local support. Recently, Homeland Security planning has recognized
the importance of EMS. A recent issue brief recommends creating
an Emergency Medical Services Administration within the Department
of Homeland Security (Cilluffo, Kaniewski and Maniscalco 2005).
B. Models of EMS Service Provision
In the United States, a number of funding and
staffing models are used to provide EMS. Distinctions are 1. organizational
type (public, private non-profit, private for-profit);
2. location/administration of service (stand alone, hospital based,
fire service based, other); and 3. size of service (from large national
corporations to small local squads).
According to the Journal of Emergency Medical
Services, 44.89 percent of EMS systems are fire department based,
6.51 percent are hospital based, and 48.60 percent are either private,
stand alone government agency, or other type (Journal of Emergency
Medical Services 2004).
In the report "Rural Implications -
2003 National EMS Survey," Mears and colleagues found that
EMS systems in rural States tend to be non-fire and non-hospital
based (Mears, Kagarise and Raiser 2004). Other classifications can
be made based on staffing (paid, volunteer, mixed paid and volunteer),
billing (billed or not billed), and type of subsidy (no subsidy,
subsidized through property taxes, sales taxes, other subsidy).
In most rural areas, EMS evolved from the same
volunteer model as fire departments. A significant difference is
that there are more ambulance calls than fire calls, longer distances
to the scene as well as longer transport times. So the time commitment
is often much greater for a community EMS volunteer than for a volunteer
fire fighter.
Many consider EMS to be in the process of "professionalization,"
undergoing a transition from a volunteer service to a paid occupation
(Nelsen & Barley 1997). In urban areas, this transition is mostly
complete. Although some consider completion of this transition to
be inevitable, others view this process as neither inevitable nor
desirable. The 1996 NHTSA EMS Agenda for the Future asserts
that provision of EMS services "will continue to be diverse
at the local level"
(McGinnis 2004).
Studying the mix of paid and volunteer EMS providers
is difficult for a number of reasons. First, all EMS providers receive
the same training, testing and certification at the State level,
regardless of whether they are paid or volunteer. Most States do
not track paid or volunteer status in their data systems.
Multiple Definitions of Volunteer. As mentioned
previously, there is no single definition of "volunteer."
In rural communities, many volunteers are paid a stipend for being
on call or for responding to an emergency and/or transporting patients,
but since they do not derive their living from this they are still
considered volunteers. In North Dakota, for example, 90 to 95 percent
of EMS workers are considered volunteer, while 45 percent report
being compensated in some way for EMS work (UND Rural EMS Initiative
2000a). In some EMS systems, they might be reported as "paid"
to the State EMS bureau, but in reality they are rarely compensated
as a fulltime professional.
States have different criteria for classifying paid and volunteer
work; a "volunteer" in one State may be classified as
"paid" in another. For example, in Sheridan County, Kansas,
EMS personnel are considered to be volunteers; however, information
posted by the Kansas EMS Board lists four paid workers for Sheridan
County. The "volunteers" cover 350-400 hours of call time
per month for which they are paid $1.10 per hour. By this State's
standard, that qualifies as "paid," although the compensation
would not be considered a primary wage.
Where a service makes use of both paid and volunteer
providers, the service itself may be classified as paid. Wendover
Ambulance in Nevada is a "paid" service, operating with
four fulltime paid workers. Fifty volunteers, half of whom come
from Salt Lake City, located 120 miles away, supplement this capacity.
For the purpose of this paper, "volunteers"
are those who are described as volunteers by informants.
II. CHALLENGES FACING VOLUNTEER EMS SYSTEMS
In frontier and rural areas, volunteers provide
most EMS. Challenges facing volunteer EMS providers include the
availability of volunteers, aging of the volunteer workforce, the
impact of national standards and testing, challenges at the primary
workplace, and maintaining skills in a low-volume environment.
A. Volunteer Availability
Many informants reported that recruiting and retaining
EMS volunteers is becoming more difficult. The National Rural Health
Association "Agenda for the Future" reports that 2000
and 2004 surveys of State EMS directors identified ongoing recruitment
and retention of personnel as the greatest challenge (McGinnis 2004).
Demographic, social, cultural and economic changes of the past 30-40
years have reduced the number of people who have time available
to volunteer. Based on population alone, frontier and rural areas
have a smaller pool of potential workers who must serve larger geographic
areas. Many frontier and rural communities face declining populations,
with older, often retired populations remaining. In many of these
communities, economic stress causes individuals to work at more
than one job when employment is available. There are often long
commutes to distant jobs. Families in which both parents work have
become common in rural communities. Many potential volunteers are
also hampered by a lack of childcare options, especially with the
unplanned, middle of the night, urgent nature of EMS.
A North Dakota survey of EMS personnel found that
the time commitment was the most significant barrier to recruiting
new providers, as well as the primary reason former EMT's give for
leaving EMS (UND Rural EMS Initiative 2000b). Reports from Nebraska
(Ullrich, Mueller and Shambaugh-Miller 2004) and Minnesota (Minnesota
Department of Health 2002) identified the same factors. In these
three States volunteers indicated that the time commitment was especially
burdensome because they are either completely uncompensated or paid
lower stipends than urban volunteers. Time away from job and time
away from family were reported as significant barriers by rural
squad leaders (UND Rural EMS Initiative 2000c). Retention is as
serious a problem as recruitment; the survey found that the average
volunteer plans on working in EMS for five years yet leaves after
three.
A number of States are focusing on ways to improve
volunteer recruitment and retention. The Rural Emergency Medical
Services Initiative at the University of North Dakota Center for
Rural Health developed an EMS Recruitment and Retention Manual (UND
Rural EMS Initiative, no date). In Wisconsin, EMS Association Director
Don Hunjadi reports that with effective recruiting tools and working
with local services, his organization has been able to attract one
volunteer for each 500 - 1000 people in a service area.
B. Aging Volunteer Workforce
Aging volunteers will one day become retiring
volunteers, further reducing the volunteer base. The 2002 report,
"A Quiet Crisis: Minnesota's Rural Ambulance Services at Risk,"
shows that in rural Minnesota, volunteers make up 77 percent of
personnel (Minnesota Department of Health 2002). In two regions
(Southwest and South Central), the volunteer percentage is 91 and
92 percent. The average age of rural volunteers tends to be older
with 45 percent over the age of 40, compared to 34 percent in urban
areas.
A 2003 Nevada survey, "Nevada Emergency Medical
Services Survey Results," documented that respondents in rural
counties "were older on average than their urban counterparts,
while at the same time Census figures show an older than average
general population in many rural counties" (Fadali, Nolan and
Harris 2003).
C. Impacts of National Standards and Testing
The National Registry of Emergency Medical Technicians
(NREMT) administers a national exam for each level of emergency
services provider in order to standardize training and testing.
A benefit of standardization is increased reciprocity of workers
among States. Some States require continuous NREMT testing; others
require it only for the first licensure exam. The NREMT website
shows only five States with no national registry exam requirement
(NREMT 2005).
o Nevada
In 2005, Nevada joined 28 other States requiring EMT Basics to pass
the NREMT exam. As of October 1, 2005, the test will also be required
for EMT intermediate and paramedics in Nevada. The two main reasons
for implementing the standardized test are reciprocity of certification
among States and to raise standards of care. Nevada EMT's who currently
hold State certification will remain certified without having to
take the national test, or if they take it and fail, they remain
certified.
The rate of those passing the NREMT exam in Nevada
to date is 50 percent. Some people opt out of the training because
they do not want to take the national test, or drop out at the time
of the test. The class commitment is 110 hours of class time plus
10 hours of clinical experience. Soon the State may add components
on Weapons of Mass Destruction and Incident Command. Adding this
material would enable the State to apply for additional Federal
funds; however, it will further increase the burden of recruiting
and retaining personnel.
o Nebraska
A 2004 Nebraska EMS workforce study found that training requirements
were cited as the second most common reason for EMT's leaving the
field (Ullrich, Mueller and Shambaugh-Miller 2004). When asked what
the most desired change was, the most common response was "fewer
requirements to maintain credentials." Similar results were
found in Minnesota and North Dakota. While the importance of advances
in technology and education as well as the public's expectation
of high level care was recognized, one service director noted that
it will take substantial financial support to make that level of
care available in low population communities.
D. Challenges at the Primary Workplace
Volunteer EMT's report that responding during
work hours is a problem. Some employers are reluctant to have employees
leave their jobs. There are particular occupations where leaving
is especially difficult, if not impossible; for example, classroom
teachers or certain medical personnel. Hourly employees and those
doing shift work report a loss of income while they are away from
their job, as do self-employed volunteers. Distance to and from
workplaces is frequently responsible for a squad's inability to
respond to a call because EMT's away at work can't get to the ambulance
quickly enough (Ullrich, Mueller and Shambaugh-Miller 2004).
One informant from rural New York Stated that
20 years ago volunteers were more abundant, as there were more businesses
that allowed employees to take time for EMS response. Now there
are fewer large businesses in the area, and the "Mom and Pop"
operations often cannot afford to let their employees take the time
to be an EMT during work hours.
While some employers are reluctant to have employees
leave during the workday to respond to emergencies, even more are
unsupportive of employees participating in long transports that
take people away from the workplace for hours or even an entire
workday. In Greeley County, Kansas, one informant stated that inter-facility
transfers are more burdensome than emergency runs, due to the time
involved. Until recently, their regular transport was to a town
90 miles away; now they sometimes transport to a town 170 miles
away, because of perceived quality of care issues. It is anticipated
that this will cause problems for both the volunteers and their
employers.
One example of extreme distances may be found
in the St. John's Valley of northern Maine. A patient transfer to
Bangor takes 7 to 8 hours roundtrip, in good weather, and they occur
two to three times a week. EMS volunteers are paid $150 per trip
for transfer to Bangor.
In Nebraska, more than one-third of volunteers
found it difficult to get time off from their job to go on EMS calls.
The Nevada study showed that more rural respondents (28 percent)
said getting time off for EMS-related duties was difficult compared
to urban residents (16 percent).
E. Maintaining Skills in Low Volume Services
The infrequency of calls for service in small
communities is another challenge for frontier and rural EMT's. Respondents
repeatedly commented on the irony that, while patient acuity and
the length of transports are often greater in rural areas, the more
highly trained personnel are in urban areas. Long transport times
challenge the lower skill levels of rural providers.
In Nebraska, 15 percent of the EMS squads responded
to 25 or fewer calls during 2003. In Nevada, some of the small services
respond to only 12 to 30 calls per year. Low volume services need
frequent training and hands-on opportunities for maintaining skills.
Frontier and rural EMS squads are less likely
than urban squads to have personnel qualified at the Advanced Life
Support (ALS) or paramedic level. The "rural ALS paradox"
or "paramedicine paradox," or lack of advanced skills
in EMS squads in rural and frontier areas, is in part a result of
the low volume environment (McGinnis 2004). Higher levels of training
and certification are harder to maintain with insufficient practice.
Further, all EMS services have the same
high fixed costs regardless of call volume. Low volume services
cannot generate sufficient revenues to pay for the higher levels
of training and commitment of paramedics (Capitol Area Rural Health
Roundtable 2001).
III. EXAMPLES OF PAID AND VOLUNTEER EMS PROGRAMS
In some States, all or most EMS workers are paid,
while in other States a high percentage is volunteer. Programs in
four States were reviewed as a sample of these differences.
A. State Programs
1. High Percentage of "Paid" Workers
Missouri
Paid emergency medical service has been the tradition
in Missouri, although as in other States, there are different levels
of paid. All workers identified as "paid" are not necessarily
paid a forty-hour per week wage. According to Steven Maxwell, Licensing
Coordinator in the State Bureau of EMS, many years ago the State
encouraged the development of advanced life support services and
today 95 to 96 percent of Missouri's EMS providers offer advanced
life support.
In urban areas, ambulance services tend to be
private; in rural areas they are often organized as ambulance districts
with taxing authority and a six-member board. Most bill for services,
but in some cases they rely only on tax revenue.
Rural recruitment is becoming a bigger problem.
This is especially true at the paramedic level with more intensive
training requirements and better-paid jobs in urban areas. Missouri
uses the National Registry exam, and at the EMT Basic level, the
pass rate is lower than at the more advanced levels. The State is
working to identify the underlying factors for these differences
in exam passage.
Staff at two frontier counties with ambulance
districts, Chariton and Mercer, provided information for this report.
According to USA Counties in Profile 2004, Chariton County has a
population of 8142 people in a county of 755 square miles located
in north central Missouri. Mercer County, located at the Iowa border
of central Missouri has a population of 3618 in an area of 454 square
miles. Both counties have lost substantial population over the last
35 years.
Both ambulance districts derive their revenue
from taxes supplemented by billing. Neither county has a hospital.
Chariton County Ambulance District makes 30-minute transports to
three small hospitals. Mercer County Ambulance District transports
are to a hospital 25 miles away.
Both offer advanced life support and train their
staff in house. In the case of Chariton County, 25 volunteer first
responders support the paid ALS units staffed by nurses and paramedics.
According to Shane Grooms, Assistant Director of the Mercer County
Ambulance District, when jobs become available, volunteers provide
a pool of potential hires. Chariton County Ambulance District Superintendent
William Pearman says recruiting workers is becoming more difficult
especially at the advanced levels. He attributes this to both the
isolated location and low pay.
Tennessee
In 1968, the Tennessee legislature gave local
governments the authority to provide ambulance service, replacing
the service supplied by funeral homes. In 1972, additional legislation
established standards for ambulance services and consequently every
county has an ambulance service. Tennessee ambulance service staff
has been paid from the beginning. Because EMS is a required community
service there is some property tax support, but most support comes
from third party reimbursement. Joe Phillips, Director, Tennessee
Division of Emergency Medical Services reported that most services
are currently breaking even.
Phillips described Tennessee as being in a unique
situation geographically and demographically. Large cities, with
tertiary care facilities and trauma centers, are situated across
the State at a distance of 100-200 miles from each other. In addition
there are three medical schools and five teaching hospitals in the
State. Tennessee is bordered by eight States and has a large inflow
of patients from five of those States (MS, AL, GA, KY and VA). Although
Tennessee has no frontier counties much of the State is rural. It
is one of several States that from the beginning have had an all
paid EMS system for urban and rural communities.
2. High Percentage of Volunteers
Nebraska
Nebraska's volunteer EMS services date back to
the mid-1960s. In small communities across the State, various civic
groups jumped in to provide ambulance service - fire departments,
Jaycees, groups of citizens. They survived on bake sales and other
local fundraisers. Today there are 423 volunteer ambulance services
in a State of 1.7 million people. Eighty percent are volunteer services,
some of which are affiliated with fire departments, others are stand-alone.
According to Dean Cole, Director of the Nebraska
Division of Emergency Medical Services, recruiting volunteers is
a huge challenge, especially in areas where the population is elderly
and sparse. Coverage during the day is the biggest problem. The
State EMS office is helping some small communities join together
in tiered services with priority dispatch, so one community can
cover for another or more than one can respond if needed. Seward
County is working with its 13 ambulance services to put them all
under one license and insurance policy so they can respond to each
other's calls.
Tradition plays a role in maintaining many Nebraska
services. They have been a valued part of the community for years.
Historically, billing was not a high priority
because the ambulance response was often provided at no charge.
As payment for service becomes critical to maintain the more costly,
modern EMS system, there is sometimes resistance on the part of
the public to pay for something that was formerly "free".
Shared professional billing services are emerging as a solution
for small agencies that do not have the expertise to manage complicated
billing procedures.
Cole says Nebraska students do well on the National
Registry exam. First responders have an 85 percent pass rate and
all levels combined are at 80 percent. Nebraska has a proactive
approach to training. They evaluated their training agencies and
instructors and monitored those programs where students did well
learning that successful instructors stick to the curriculum, test
students often, have others monitor their style, and teach more
than one class per year.
Nebraska learned that students who failed the
national test often had difficulty reading. So in advance of taking
EMT classes, students must take a reading comprehension inventory
prepared by the University of Nebraska-Lincoln Adult Education Department.
While the overall class material is rated at an 8th grade level,
required course readings are rated at 10th grade through college
sophomore level. If students do not do well on the inventory, organizers
urge that they first work on reading skills before beginning EMT
training.
The Nebraska EMS Division, in cooperation with
the University of Nebraska-Lincoln, has developed eight online learning
modules. Now, in addition to taking classes, students will be able
to improve their preparation for the test using online materials.
The EMS Division is also developing online courses for EMS instructors
to help them become more effective when using telemedicine instructional
technology.
Based on the continued growth of minority populations,
particularly Hispanics, the State EMS Division is beginning to look
at second language issues. While minorities are encouraged to volunteer,
many have very demanding work schedules, leaving little time for
volunteering.
Wisconsin
Rural Wisconsin EMS relies heavily on volunteers.
Wisconsin is a home rule State, and every municipality has the responsibility
to provide its own EMS either directly or through a contractual
arrangement. In urban areas, these services are staffed by full
time paid providers. In rural areas, coverage tends to be by volunteers.
Most volunteers receive some financial compensation
for taking calls, for example, $10 per call or $50 per month. Since
fewer volunteers are available during daytime hours, more services
are paying a stipend for daytime service. Most ambulance services
bill for services.
In 2002, the Wisconsin EMS Association (WEMSA)
organized a Statewide effort to train individual ambulance services
how to recruit new volunteers. WEMSA had found that simply putting
out a call for volunteers was not effective. People failed to respond
because they tended to think they would respond later, were intimidated
by the responsibility and training, or perhaps had questions but
were reluctant to ask them.
The focus of the volunteer recruitment effort was a Statewide media
blitz coupled with local community events, such as an open house,
spaghetti dinner or some other gathering to bring people together.
WEMSA believes that when people see others turning out for a group
information session, they are more likely to attend. Immediate follow-up
with attendees is essential. Another tool used is inviting prospective
volunteers to the workplace and having them ride along on ambulance
runs.
Whitewater, Wisconsin, a city of 8,000 people, was close to being
forced to hire workers to keep their service from closing. After
being trained to conduct a recruiting campaign, they gained 45 volunteers.
Twenty-eight went through the training, and 24 now serve with the
department.
A new Statewide recruitment drive is being planned
for 2006. The Wisconsin EMS Association has made their recruitment
tools available to other agencies.
B. Local Programs
1. Paid and Volunteer: Two Communities with
Shared Management
St. John's Valley, Northern Maine
Two adjacent towns located in frontier Aroostook
County in the St. John's Valley of Northern Maine are each served
by a town-operated ambulance service. Madawaska Ambulance Service
is operated by all paid staff, the other, Ambulance Service Incorporated
in Fort Kent, is primarily a volunteer service. The same person,
John Labrie, manages both services.
Madawaska. For twenty hours per week, Labrie
manages a full time paid crew, including a paramedic. The crew is
housed at the fire station in Madawaska, a paper mill town of 5000
residents. The emergency service has benefited in the past from
support from local government and the mill, which needs an immediate
response when there is an accident. Five years ago there was an
extensive local government subsidy. This year Madawaska Ambulance
Service, which has an annual budget of $350,000, collected $250,000
through billing and collections and expects to be self-sufficient
next year. An outside private company does billing.
Fort Kent. Labrie is also paid 16 hours
per week to oversee the volunteer service in Fort Kent, Maine, a
town 22 miles away. Labrie has a 0.5 FTE paid assistant in Fort
Kent who helps manage the ambulance.
Thirty-six volunteers and five ambulances serve
an area of 15,000-17,000 people. Two ambulances are stationed at
the Northern Maine Medical Center in Fort Kent, and one in each
of three towns 20-30 minutes away. These "volunteers"
are paid $2-3 hour for being on call and $25 for responding to a
call. Volunteers are on call for three 24-hour shifts a week.
Despite a strong tradition of volunteering in
the area, it is becoming more difficult to recruit new volunteers.
But tradition aside, Labrie says there has to be some remuneration
for the amount of effort expected from these volunteers to compensate
them for their time commitment and to improve retention. As stated
previously, volunteers are currently paid a stipend for the 7-8
hour trip to transport patients to Bangor. In addition to Labrie,
EMS coordinators in other States share his belief that EMS volunteering
is far more demanding than most other types of volunteerism.
Training is linked to the Northern Maine Community
College in Presque Isle, about 60 miles away, and is paid for by
Ambulance Service Incorporated. The training combines students traveling
to Presque Isle, faculty coming to the hospital, and some lectures
delivered by telemedicine. Fort Kent is located near the Canadian
border and has a large French-speaking population. Prospective volunteers
must pass an English language test prior to taking the EMT course,
but clearly their bilingual skills are an asset.
Labrie expects that eventually Fort Kent will
have a fully paid service. Ambulance Service Incorporated has operated
for 30 years and remains a volunteer service to keep costs down
for the 12 small towns that together subsidize 25 percent of its
operation. Labrie explained that if the ambulance service were staffed
by full time paid EMT's, the budget would increase by 75 to 100
percent. Billing and collections has been moved to the billing department
at Northern Maine Medical Center and the collection rate is improving.
From his vantage point, Labrie says the quality
of the two services is equal, but the response time of Madawaska
is faster because paid staff are on duty at all times.
2. Kansas Frontier Experience
The Kansas EMS office provided information on
paid and volunteer workers in their 52 frontier counties. For the
purpose of comparison they also provided the same information for
the two largest counties. Data for 2005, 2000, and 1998 (the year
they began collecting this data) was received. Unlike other States,
frontier counties in Kansas have experienced increases in the numbers
of volunteers since 1998 as well as increases in the numbers of
paid personnel. The same pattern was true for the two urban counties.
But those increases do not translate to increased
worker availability. In some cases workers are kept on the roster
even when they move. The experience of the following two frontier
counties, exemplifies the difficulties faced largely by volunteer
services in remote, sparsely populated areas of Kansas.
Greeley County, Kansas
Greeley County Ambulance is a completely volunteer
service. Greeley County is located in western Kansas and has a population
of 1500 people in a 778 square mile area. Although Greeley County
Ambulance lists 21 volunteers on their roster, ten make about 90
percent of the runs. The county pays the service $7.00 per EMT per
run, for up to four EMT's per run. These payments do not go to the
volunteers but into an equipment and expense fund. The director
receives $350 per month, recently increased from $156 per month.
In addition to providing emergency care, Greeley County Ambulance
transports patients to the hospital for tests, often without reimbursement.
Recruiting new, active volunteers is an ongoing
problem. Greeley County Ambulance pays for all training and certification
fees. The county pays for most continuing education and reimburses
students for their initial training. Students have 50 percent of
the training costs reimbursed after passing the national exam and
the remaining 50 percent after one year of service as an EMT. In
the last two years, two courses were held and as a result five EMT's
joined the ambulance service. Of these, two will leave for college
within the next year so the net gain over two years is three volunteers.
Economic pressures are believed to limit the involvement
of new volunteers. Greeley County Ambulance is considering paying
for on-call time and paying an hourly rate for transports directly
to the techs. The national test is not a deterrent to volunteering,
but after the initial National Registry test, most EMT's in Kansas
maintain only their State certification, which has fewer requirements.
One important issue is the need for higher levels
of skill, especially in rural areas. The town of Tribune, where
Greeley County Ambulance is based, has an 18-bed Critical Access
Hospital. People living close to town and those whose medical needs
can be served by that facility, have a quick transport. But for
people further away, or for those who need a higher level of care,
there is a long transport, and often those patients require more
advanced skills during transport.
Greeley County officials do not think it can afford
a paid service. Billing is done by a volunteer who is paid a flat
rate of $8 per claim, with no additional fee for follow-up and/or
clarifications. Discussions with the county hospital billing department
were initiated, but both the county commissioners and the ambulance
service had issues with paying a higher fee.
Sheridan County, Kansas
Sheridan County is a 900 square mile county with
about 2000 residents. A county-subsidized EMS program is based in
Hoxie, Kansas where the Sheridan County Health Complex, a Critical
Access Hospital, is located. Sheridan County EMS Director Debbie
Kaufman says attracting volunteers is becoming increasingly difficult
as the population decreases and EMS becomes more of a profession.
Recently, Kaufman met with other members of the 18-county EMS region
of northwest Kansas to discuss the extreme shortage of volunteers.
There was a sense that in five years, without additional support
or restructuring, they will not be able to continue to maintain
volunteer services. Regionalization has been considered but, due
to distances, there are concerns about the increased response times
to reach patients.
The county began financial support in 1975. Currently,
the county provides one-third of the budget of Sheridan County EMS
with the remaining two-thirds from billing and collections. The
service fields about 200 calls per year, an average of four per
week. One-third of the calls are transfers - 85 miles to Hays, Kansas,
or 260 miles to either Wichita or Denver. Volunteers receive a trip
reimbursement stipend. There are four EMT's in town, plus one first
responder. A few EMT's in other parts of the county help out on
an informal basis.
C. Innovative Approaches to Maintaining Frontier
EMS
Research identified two models, which have been
developed to help maintain and support frontier ambulance services.
One model is the cross training of hospital staff as EMT's and the
other is a creative funding mechanism used in Utah.
Hospital cross training of staff has several advantages.
The workers are already onsite and those that are selected for training
have hospital jobs that can be interrupted. The training benefits
the workers with additional career opportunities as well as providing
additional EMS staff. Examples of two hospitals that provide emergency
medical training to regular staff members in order to increase the
availability of EMS workers follow.
The State of Utah has tackled EMS funding in an
unusual but effective way. Utah takes a creative approach to generating
revenue by adding a surcharge on all criminal fines.
Cross-Training Hospital Staff as EMT's
1. Owyhee Community Health Facility, Nevada
The Owyhee Community Health Facility is a 15-bed
hospital with a staff of 70 located on the Owyhee Indian reservation
in frontier Elko County. The hospital provides EMS training annually
to non-medical hospital workers. This approach has been successful
and eight trained hospital workers are currently part of the ambulance
service. When needed for an emergency, they are able to leave their
regular position to assume emergency medical duties. Their rate
of pay depends on the service they are providing. While working
as an EMT, they are paid as an EMT; while working in their daily
job, they are paid their regular salary.
The ambulance averages 160 calls each year, with
75 percent of them being transfers to other facilities in larger
communities such as Elko, Nevada (96 miles) or Boise, Idaho (142
miles). They respond to both reservation and non-reservation areas
within a 50-mile radius, which crosses the Idaho/Nevada State line.
2. Margaretville Memorial Hospital, New York
The ambulance service operated by Margaretville
Memorial Hospital has a similar program in rural Delaware County,
New York. The ambulance service area is approximately 706 square
miles with a population of about 4200, with seasonal increases.
Hospital staff members are offered EMT training,
which is reimbursed by the State, and once licensed, they augment
the EMT pool. During daytime hours, when working as EMT's they are
paid their regular plus an extra hourly rate for time spent on a
call. Nights and weekends are covered by on call staff paid a stipend.
The hospital and staff are reported to be satisfied with this arrangement.
Among the EMS-trained staff members, certain occupations are more
available for emergency response than others. For example, a housekeeper
is usually more readily available than an operating room technician.
3. Utah Criminal Fine Revenue
In the State of Utah, every criminal conviction
carries a surcharge, a portion of which benefits EMS (Utah Code
Section 63-63a-1). In 2005 the State EMS program received $2.5 million
from these surcharges. These funds are used for administration,
EMS training programs in high schools, competitive grants to ambulance
services, and a per capita disbursement to counties. Many frontier
and rural EMS services have used this source to purchase new ambulances
and other equipment.
D. Issues Related to Billing and Collections
There was a great variability of knowledge about
generating revenues through billing and collections among rural
and frontier ambulance services. Many services do no billing at
all and were therefore the least informed about the reimbursement
system. At the other end of the spectrum are services that aggressively
make every effort to capture all possible reimbursements. Some ambulance
services turn the billing over to another department or agency and
are not themselves informed about the billing and collection procedures.
Outside billing services were generally reported
as a positive solution to billing difficulties. These are often
contractual relationships where the billing and collections are
either performed by a private company, a local health provider or
hospital. Experienced billing services provide efficiency, knowledge
of the process and more orderly collection of fees.
For example, the Wendover, Nevada ambulance is
fully supported by its billing and collections. In order to insure
that responders' narratives on run forms are complete and appropriate
for billing Medicare and other payors, the service pays a $5 trip
completion bonus each time the volunteers submit accurate and complete
information.
IV. SUMMARY
In most cases, the decision to operate a volunteer
ambulance service rather than a paid service is not a "choice,"
but based on real or perceived financial limitations. It was frequently
stated that (a) local governments cannot afford to provide the service,
or (b) operating a volunteer service holds costs down for the local
government. In some rural areas, camaraderie and tradition are strong
factors in keeping a volunteer service.
Challenges to Staffing and Financial Sustainability
Several issues were raised numerous times
and reflect current concerns of EMS staff working at both the State
and community level.
- Availability of volunteers. EMS volunteers
make a far greater time commitment than most civic or nonprofit
organization volunteers, both in terms of responding to emergencies
and training. Time pressures of job and family reduce time available
to volunteer. Even communities that report a strong tradition
of volunteerism are concerned about the changes underway. They
acknowledge that both volunteers and their employers are finding
it more difficult to make the commitment to EMS.
Increased training and licensure requirements impact recruitment
and retention of volunteers. While training is often cited as
a drawback to volunteering, training demands are more likely to
increase than decrease in the future. Nebraska's aggressive approach
to training may provide a good model for other States.
- Billing as a revenue source. At this time,
a minority of rural and frontier ambulance services maintain their
operations through efficient billing and collection systems. For
many ambulance services, billing and collection is either informal
or not a high priority.
This stems partially from the fact that in the past such services
were sometimes offered at no cost to the users.
EMS systems have costs whether labor is fully paid, volunteer,
or volunteer with a stipend. For many communities initiating billing
to cover all costs is a hurdle that must be overcome in order
to assure continued operations. Community perceptions appear to
make it more difficult to institute fees for previously "free"
service. It is more difficult when the public knows the services
are provided by "volunteers," but outreach and public education
should help make the transition successful.
- Insufficient volume to cover costs. Emergency
response and transport is an important health care service highly
valued by the public. A high volume of services is required to
reach or approach financial self-sufficiency. In most frontier
and many rural areas, there will always be an insufficient number
of services to cover all costs. Given the vast distances and low
population of communities, it is difficult to always have a paid
crew available. Low population areas need creative solutions and
most will always require some form of subsidy.
As systems change, one option is to work toward
a blend of paid and volunteer EMT's within small ambulance services.
There are a variety of types of blended systems.
Blended Systems: Successful Models
o One Paid Staff Person
A model for small communities consists of one paid staff person
working 40 hours a week to respond as well as manage the administrative
functions. Volunteers provide the rest of the staffing. This model
is used in Wyoming. Except for five cities, most Wyoming ambulance
services are sta
ffed with a paid director and volunteers who receive minimal pay
for carrying a pager or responding to a call. In sparsely populated
Wyoming, some individuals volunteer for more than one ambulance
service.
o Multiple Funding Sources
Funding needs to be blended as well as staffing. In most localities
there is some State and local support for training and equipment.
Some services also receive revenue from billings. Missouri's use
of ambulance districts, with taxing authority, is yet another approach.
Services that respond to very few calls per month will never cover
their costs through billing alone.
o Shared Services
Nebraska encourages cooperation among small services for dispatch
and liability insurance as a way to improve efficiency and hold
down costs. Similar cooperation might be encouraged for billing
as well. Multi-agency cooperation is a positive way to maximize
the limited resources found in rural communities.
Future Research
Research on frontier and rural EMS needs to identify
methods to sustain EMS systems in small and/or geographically isolated
communities.
While many frontier and rural communities are
providing EMS using a number of creative staffing and financing
solutions, other communities are increasingly at risk from an EMS
system in distress. To inform policy, it is important that future
research identify fragile communities and ways that they can become
sustainable. Despite anecdotal evidence that frontier and rural
communities experiencing population losses may have difficulty maintaining
their EMS systems, the lack of data hinders the ability to help
them.
Future research focused on how to support frontier
EMS might include:
- Work with national EMS data collection projects
to obtain county-level data on EMS. County-level data is important
for three reasons: (a) "frontier" is frequently defined at the
county level; (b) many public services, including EMS, are administered
at the county level; (c) other useful analytic tools, such as
the USDA Economic Research Service (ERS) economic and other typologies,
are defined at the county level. The database for the National
EMS Information System (NEMSIS) being developed for NHTSA will
be completed late in 2006 and will include county-level data.
Other partners include NEDARC, the National EMSC Data Analysis
Resource Center.
- Identify EMS systems at risk. Communities
that (a) are too small to support a private EMS service, (b) are
losing the battle to attract and retain volunteers, and (c) cannot
finance a paid EMS service, are at risk of losing EMS services,
putting people at risk.
- Identify factors associated with at risk
EMS. Analysis of demographic, social, economic, cultural,
and political factors associated with the inability to assure
adequate EMS coverage may lead to (a) easier identification of
EMS systems at risk, (b) better understanding of why these systems
are at risk, and (c) possible sustainability solutions.
- Work with communities to develop local solutions.
The very local nature of EMS provides both opportunities and
challenges. It is unlikely that a single strategy will benefit
all communities in need. Participatory research can expose communities
and researchers alike to new options and possibilities, and provide
the technical assistance that communities may need to implement
a sustainable EMS service.
- Recognize the need for a public EMS safety
net. Not all communities will be able to support an EMS service.
Additional grant programs and subsidies may be necessary to ensure
adequate nationwide EMS coverage.
V. REFERENCES
Capitol Area Rural
Health Roundtable (2001). "Rural EMS:
Financing Preparedness." Capital
Area Rural Health Roundtable Notes 5(2):
4 p. The Center for Health Policy & Ethics, George Mason
University.
Available (9/02/05).
Cilluffo, F. J., D.
J. Kaniewski and P. M. Maniscalco (2005). Back
to the Future: An Agenda for Federal Leadership of Emergency Medical
Services. Washington,
DC, The George Washington
University Homeland Security Policy Institute: 16 p. Available
(5/23/06).
Erisman, G. (2005).
"Rural
Emergency Response - The Safety and Health Safety Net."
Available (9/02/05).
Fadali, E., Nolan, J., & Harris, T.
(2003). “Nevada
Emergency Medical Services Survey Results,” Rural Emergency
Medical Services Outreach Project, Elko,
NV: Great
Basin College. Available (5/23/06).
Journal of Emergency Medical Services (2004)."JEMS
2004 Platinum Resource Guide." Available (5/23/06).
Kansas Board of EMS, “EMS Board Registry Data,
2005,” Topeka, KS.
McGinnis, K. (2004), “Rural
and Frontier Emergency Medical Services: Agenda for the Future,”
Kansas City, MO:
National Rural Health Association. Available (5/23/06).
Mears, G., Kagarise, J., Raiser, C., (2004).
"Rural Implications, Appendix 2 of the 2003 National Emergency
Medical Services (EMS) Survey."
Minnesota Department of Health (2002). “A
Quiet Crisis: Minnesota’s
Rural Ambulance Services at Risk,” Office of Rural Health &
Primary Care, Minnesota Department of Health. Available (8/2/05).
National Association of State EMS Directors, Member
Directory. Available (2/18/05).
National EMSC Data Analysis Resource Center (NEDARC),
“2003 EMSC Data Collection System,” Available ( 4/01/05) at http://www.nedarc.org
(no longer available).
National
Registry of Emergency Medical Technicians (2001). State Office
Information. Available (8/2/05).
Nelsen, B.J., & Barley, S.R. (1997). “For
Love or Money? Commodification and the Construction of an Occupational
Mandate,” Administrative Science Quarterly, Vol. 42, No.
4, 619-653.
National
EMS Information System Project
(NEMSIS). Available 9/14/05.
Ullrich,
F, Mueller, K., & Shambaugh-Miller, M. (2004). “Emergency
Medical Services Volunteer Personnel in Nebraska:
Workforce of the Present, Hope for the Future?” Lincoln,
NE: Nebraska
Center for Rural Health Research. Available
(8/2/05).
UND Rural EMS
Initiative (2000a). North
Dakota EMS Providers' Demographic
and Work Characteristics. Fact
Sheet #2. Grand Forks, ND, University of North Dakota School
of Medicine & Health Sciences: 2 p. Available (9/02/05).
UND Rural EMS
Initiative (2000b). Recruitment
and Retention Issues Among North Dakota EMS Personnel. Fact Sheet #3. Grand Forks, ND, University
of North Dakota School of Medicine & Health Sciences: 2
p. Available (9/02/05).
UND Rural EMS
Initiative (2000c). Fact
Sheet Number 3: Recruitment and Retention Issues Among North Dakota
EMS Personnel. Fact Sheet #3.
Grand Forks, ND, University of North Dakota School of Medicine &
Health Sciences: 2 p. Available (9/02/05).
UND Rural EMS Initiative
(no date). EMS
Recruitment and Retention Manual (online). Grand Forks, ND, University of North Dakota School
of Medicine & Health Sciences. Available (9/02/05).
USA
Counties in Profile. Available 8/2/05.
Utah
Code,
Title 63--Chapter 63a--Crime Victim Reparation Trust, Public Safety
Support Funds, Substance Abuse Prevention Account, and Services
for Victims of Domestic Violence Account. Available (8/11/05).
Appendix A: Frontier and Rural Expert
Panel
PETER G. BEESON
4900 South 71st Street
Lincoln, Nebraska 68516
(402) 486-0858
pgbeeson@neb.rr.com
MARTIN BERNSTEIN
Chief Executive Officer
Northern Maine Medical Center
143 East Main Street
Fort Kent, Maine 04743
(207) 834-3155
martin.bernstein@nmmc.org
PATRICIA CARR
Director, Primary Care and Rural Health Unit
Office of the Commissioner
Alaska Department of Health and Social Services
P.O. Box 110601
Juneau, Alaska 99811-0601
(907) 465-8618 phone/ (907) 465-6861 fax
pat_carr@health.state.ak.us
GAR ELISON
Utah Medical Education Council
230 S. 500 E
Suite 550
Salt Lake City, UT 84115
801-526-4550
gtelison@utah.gov
CAROLINE FORD
Director, Office of Rural Health,
Center for Education and Health Services Outreach
Univ. of Nevada School of Medicine,
411 West 2nd Street
Reno, NV 89503
775-784-4841
cford@unr.edu
REBECCA SLIFKIN
Cecil G. Sheps Center for Health Services Research
CB# 7590, 725 Airport Road
University of North Carolina at Chapel Hill
Chapel Hill, N.C. 27599-7590
919-966-5541
slifkin@mail.schsr.unc.edu
KARL STAUBER
President, Northwest Area Foundation
60 Plato Boulevard East
Suite 400
St. Paul, MN 55107
Telephone: 651-224-9635
kstauber@nwaf.org
FEDERAL PROJECT OFFICER
EMILY COOK
Office of Rural Health Policy
HRSA/DHHS
Room 9A-55 Parklawn Building
5600 Fishers Lane
Rockville, MD 20857
301-443-0835
ECook@hrsa.gov
FRONTIER EDUCATION CENTER:
NATIONAL CLEARINGHOUSE FOR FRONTIER COMMUNITIES
CAROL MILLER
Executive Director
HCR 65 Box 126
Ojo Sarco, NM 87521
505-820-6732
carol@frontierus.org
Appendix B: Contact List
Randy Cardonell, Volunteer
Greeley County EMS
P. O. Box 399
Tribune, KS 67879
Dean Cole, Director
Nebraska Division of Emergency Medical Services
Box 95007
Lincoln, NE 68509-5007
402-471-0124
Pat Delameter, EMS Director
Margaretville Memorial Hospital
42084 State Highway 28
Margaretville, NY 12455
845) 586-2631
Rosanna Gignac, EMS Coordinator
University of Nevada School of Medicine, Elko
701 Walnut
Elko, Nevada 89801
775-934-5129
Shane Grooms, Assistant Director
Mercer County Ambulance District
Princeton, MO 64673
660-564-2467
Mary Hedges, Executive Director
Minnesota EMS Regulatory Board
2829 University Avenue SE, Suite 310
Minneapolis, MN 55414-3222
612-627-6000
Don Hunjadi, Director
Wisconsin EMS Association
21332 7 Mile Rd.
Franksville, WI 53126-9769
414-431-8193
Leslie Johnson, Program Manager, Certification
and Grants Program
Utah Bureau of Emergency Medical Services, Bureau of EMS, Department
of Health
Box 142004
Salt Lake City, UT 84114-2004
801-538-6435
Debbie Kaufman, Director
Sheridan County EMS
RR 1, Box 941
Hoxie, KS 67740
785-675-3364
John Labrie, Director
Madawaska and Ft. Kent (ME) EMS Services
428 Main St.
Madawaska, ME 04756
207-728-6522
Jim Mayberry, EMS Program Manager
Wyoming Department of Health
Hathaway Building, Room 446
Cheyenne, WY 82002
307-777-7955
Joe Moreland, Policy and Program Analyst
Kansas Board of EMS
900 SW Jackson
Landon State Office Building, Room 1031
Topeka, KS 66612-1228
785-296-7412
William Pearman, Superintendent
Chariton County (MO) Ambulance District
212 South Weber Avenue
Salisbury, MO 65281
Kenny Pete, EMS Coordinator
Owyhee Community Health Facility
P. O. Box 130
Owyhee, NV 89832
Joe Phillips, Director
Tennessee Division of Emergency Medical Services
425 Fifth Avenue, North
Nashville, TN 37247-0701
615-741-2584
Laura Snyder, Owner
Wendover Ambulance
P.O. Box 2530
Wendover, NV 89883
(775) 664-2081
Garry Steele
Nebraska EMS Training Coordinator
Box 95007
Lincoln, NE 68509-5007
Dan Williams, Chief
Wisconsin Emergency Medical Services
WI DHFS, Division of Public Health
P.O. Box 2659
Madison, WI 53701-2659
608-261-6870
Gary Wingrove
Gold Cross/Mayo Medical Transport
501 6th Ave NW
Rochester, MN 55901
612-366-3532
Appendix C:
Frontier Education Center EMS Information Request, April 2005: Response
Summaries
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