U.S.
Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
This document was prepared under HRSA contract
# 250-03-0022, U.S. Department of Health and Human Services, Health
Resources and Services Administration, Office of Rural Health Policy.
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Acrobat Version (273 kb)
Contents
Foreword
Introduction
Methods
Results
Park City, Utah Town Hall Meeting
New England Area Town Hall Meetings
Appalachia Town Hall Meetings
Findings
Discussion
Funding/Resources
Advocacy
Recruitment and Retention
Training
Professionalism, Self Image
Conclusion
References
APPENDIX A: Acknowledgements
Contributors and Reviewers
APPENDIX B: REMSTTAC Stakeholders'
Group
Foreword
Rural health
care is often under-represented in discussions and debates concerning
health care delivery. This is particularly true of rural Emergency
Medical Services (EMS). In an environment that relies largely on
a volunteer workforce, the ability for EMS agency personnel and
individual Emergency Medical Technicians (EMTs) to have their voices
heard at policy and decision making levels is challenging. The Institute
of Medicine recently noted in their EMS: At the Crossroads
(2006) report "EMS, for example, is unlike any other field
of medicine-over one-third of its professional workforce consists
of volunteers." (p. xiii)
HRSA's Office of Rural Health Policy (ORHP) has,
since its inception, been concerned about ensuring that rural issues
are well represented at a Federal policy level. HRSA's Rural EMS
and Trauma Technical Assistance Center (REMSTTAC) was charged with
the task of helping to ensure that there was a conduit for issues
and concerns to be channeled up from the rural EMS community to
ORHP. REMSTTAC has assumed that responsibility and conducted a series
of town hall meetings in three rural regions of the country. This
report describes those meetings and the challenges and concerns
that EMS systems in rural America are facing at the grass roots
level.
Clearly the findings contained in this report
cannot be generalized to "all" rural EMS systems. However,
the fact that the findings are consistent with other recent documents
such as the Rural and Frontier EMS Agenda for the Future
and the Institute of Medicine's EMS: At the Crossroads report
indicates that there are some common challenges that emerge wherever
ambulance wheels roll down rural roads. HRSA, ORHP, REMSTTAC and
others will have to work together as they attempt to address the
issues identified in this report.
We acknowledge those who took the time to participate
in one of the town hall meetings. Likewise we appreciate all rural
residents who set aside what they are doing when the pager tones
to respond to their neighbor's emergency medical needs.
Marcia K. Brand, Ph.D. |
Nels D. Sanddal, Director |
Associate Administrator
for Rural Health, HRSA |
Rural EMS and Trauma
Technical Assistance Center |
Emergency Medical Services
(EMS) struggle to meet the needs and demands of citizens in communities
across the nation. For rural or frontier communities it is becoming
even more challenging to meet the community's needs for prehospital
emergency care.
EMS Systems face numerous challenges. First, and
foremost, EMS has no clear home as part of the health care system.
Although EMS is often the first to treat patients who are injured
or become ill, EMS' place within the health care system has yet
to be clearly defined.
During a time when much of the country is preparing
for large-scale emergency events, rural and frontier America is
often faced with trying to find enough volunteers to answer routine
calls for a single sick or injured patient. Rural EMS confronts
challenges that are much different than those of its urban neighbors.
Rural problems often involve a lack of resources, difficulty in
recruitment and retention of prehospital providers, and a lack of
medical oversight.
With the creation of the Rural EMS and Trauma
Technical Assistance Center (REMSTTAC), funded by the Health and
Human Resources Services Administration (HRSA), Office of Rural
Health Policy (ORHP), it was essential to inform a broad constituency
about REMSTTAC and its purpose. It was equally important to solicit
first-hand information concerning the challenges facing rural EMS
providers - from their perspective. The purpose of the Town Hall
Meetings was three fold: 1) to provide exposure for REMSTTAC, 2)
to be a conduit to and from ORHP to those working in the field of
rural and frontier EMS, and 3) to discuss key features of the Rural
and Frontier EMS Agenda for the Future. Additionally, town hall
meetings provided a forum for information gathering for the EMS
workforce study being conducted by National Highway Transportation
Safety Administration (NHTSA) with a wide variety of partners. While
most of these partners do not specifically represent rural issues,
strong rural representation is involved in the NHTSA process, including
REMSTTAC, ORHP, the National Association of State EMS Offices (NASEMSO),
the National Rural Health Association (NRHA) and others.
METHODS
The concept of regional information gathering
workshops was identified in the original solicitation by ORHP to
create a Rural EMS & Trauma Technical Assistance Center, and
these workshops were included in the Earthtalk Studios / Critical
Illness & Trauma Foundation (CIT) response to the solicitation.
(Earthtalk and CIT, under contract with ORHP, are responsible for
the operation of REMSTTAC). The need to gain first-hand knowledge
of the needs of rural EMS providers was confirmed as a priority
activity following the award of the contract, during the first meeting
of a REMSTTAC Stakeholder Group created to oversee the project,
and was supported by the ORHP project officer. The initial meeting
was held in conjunction with the annual grantee meeting for the
Rural Automated External Defibrillator (RAED) program; thereafter,
adjustments were made to the venue selection process, and the Town
Hall meetings became freestanding.
As with each of the tasks associated with the
REMSTTAC contract, a task group of REMSTTAC staff and individuals
from the Stakeholder Group was assigned to carry out the project.
Teri L. Sanddal, Associate Director of REMSTTAC, was the lead staff
person; she was supported by Heather A. Soucy, Program Support Specialist
for REMSTTAC. Stakeholders on the task group included Patrick Malone,
Dan Summers, Marilyn Jarvis, and Evan Mayfield.
The task group, in consultation with the broader
group of Stakeholders, determined the three general locations for
the meetings. A preliminary timeline and meeting agenda was agreed
upon and created through a consensus process. The task group assigned
a local coordinator to assist with the Town Hall Meetings. This
task was assigned to Patrick Malone and Dan Summers for New England
and Appalachia, respectively. Feedback on the events was solicited
through formal written evaluation questionnaires. The questionnaires
were structured on a modified Likert scale with a semantic differential
rating system. Evaluation questionnaires were distributed and collected
on-site.
The agenda for each of the meetings included
four general sessions:
- Who is REMSTTAC, and what does REMSTTAC do?
- Overview of the Rural and Frontier EMS Agenda
for the Future
- Assessment of workforce need (not included
in Park City, UT)
- Discussion of current challenges to Rural EMS
including perceived solutions to those challenges.
RESULTS
Park City, Utah, Town Hall Meeting
The first of the town hall meetings was hosted
in Park City, Utah, in conjunction with HRSA's annual Rural Automated
External Defibrillators (RAED) Grantee's meeting on October 4, 2004.
The 4-hour meeting began with a series of key presentations: 1)
a REMSTTAC overview, 2) Rural EMS Performance Improvement Efforts,
3) Challenges to Rural Trauma Care, and an overview of the Rural
and Frontier Agenda for the Future. Following these presentations,
an open forum and discussion was conducted. Because the meeting
was held jointly with the RAED conference, much of the discussion
was more focused on matters pertaining to the RAED grant support
and technical assistance.
The most important aspect of these discussions
was the clear identification of the need for standardized EMS data
collection. A consensus was reached among the participants pertaining
to the need to use a standardized data set. This led to a discussion
concerning the National Emergency Medical Services Information System
(NEMSIS) for such evaluation efforts. REMSTTAC staff, and others,
suggested to the audience that using NEMSIS would clarify the standard
definitions and help improve reporting quality across all grantees.
Discussions focused on how REMSTTAC could be more supportive of
the RAED grantees, particularly in the area of data collection.
Other discussion points centered around how REMSTTAC could help
promote and communicate with rural and frontier EMS systems through
its Web site, hosting a library of literature that would have information
about such topics as: funded vs. not funded trauma and EMS systems,
how EMS systems collaborate to make rural EMS work successfully,
as well as hosting and distributing the Rural and Frontier EMS
Agenda for the Future, HRSA Model Trauma Care Plan, and
other key EMS/trauma documents.
Forty-five individuals attended this inaugural
Town Hall meeting, representing 37 States and one territory. All
participants were asked to fill out an evaluation of the meeting.
Using a modified Likert scale with 1 being poor or not meeting expectations
to 5 being excellent, the mean score for meeting the audience's
personal objectives was 3.80; presenters scores ranged from 3.2
to 3.8, the overall meeting score was 3.95.
At the conclusion of the meeting in Park City,
REMSTTAC staff and the ORHP Project Officer realized that, although
the meeting in Park City was a success, REMSTTAC was still not reaching
the audience that the Town Hall Meetings were designed to reach
- that being "frontline" EMS providers and rural health
care professionals. In order to reach this audience, REMSTTAC conducted
and held the subsequent meetings in multiple locations within an
area and spoke directly to those working in the field. It also was
apparent from the Park City meeting that more time was needed for
group discussion and identification of pressing topics. Subsequent
meetings were adjusted to allow this additional time.
New England Area Town Hall Meetings
The second sets of Town Hall Meetings were hosted
in the New England area and were held between October 16 and October
19, 2005. Meetings took place in Lewiston, Maine; Burlington and
St. Johnsbury, Vermont; Bartlett, New Hampshire; and Newport, Rhode
Island. The final meeting in Newport involved a presentation of
findings to the New England EMS Council, which represents EMS agency
personnel from six States.
REMSTTAC's local coordinator was Patrick Malone,
who represented the New England EMS Council and the Rural EMS Initiative
of the University of Vermont, Burlington. Mr. Malone also currently
serves on REMSTTAC's Stakeholder group. The Town Hall meetings in
New England resulted in the opportunity to engage in discussions
with more than 100 individuals. Audiences included State EMS officials,
hospital personnel, State offices of rural health, local EMS service
directors, and "street level" Emergency Medical Technicians
(EMTs). The agenda for these meetings was modified from Park City
to accommodate the addition of the NHTSA Workforce Assessment1
and to allow for more audience discussion. In order to keep the
meeting length to four hours and accomplish the stated goals, more
printed materials concerning REMSTTAC, along with a pocket size
CD-ROM of the Rural and Frontier Agenda for the Future, were
provided at registration. This strategy allowed more time for discussion
among the participants and staff.
The most pressing issues identified in New
England included:
Funding |
Advocacy |
Training |
Public Education |
Lack of an EMS System |
Patient Transfers |
Recruitment & Retention |
EMS Service Management |
Preparedness |
Geographic Challenges |
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When asked to rank and prioritize the top three
challenges from the above list, participants in all four locations
assigned the following ranking: 1) funding, 2) advocacy, and 3)
recruitment and retention of volunteers.
Evaluations from these meetings indicated that
the new format, with more time for open discussion of the issues
was a positive adaptation. Again, using a modified Likert scale
with 1 equaling poor and 5 equaling excellent, the mean score for
meeting objectives being met were 3.91 and overall rating of the
meeting was 4.35.
Appalachia Town Hall Meetings
The third and final sets of Town Hall Meetings
were conducted in the Appalachian Region. These meetings were held
between April 22 and April 25, 2006. Five meetings were conducted,
including a televideo conference that engaged three additional locations.
Meetings were hosted in Hiller, PA; Grafton WV; Morgantown, WV (included
televideo connection to the towns of Boone, Braxton, and Rainelle2),
Franklin, WV; and Charleston, WV. Dan Summers from the Center for
Rural Emergency Medicine (CREM) was the local coordinator and is
the representative from CREM to the REMSTTAC Stakeholder committee.
At these sites, REMSTTAC again led discussions with more than 100
individuals who included physicians, nurses, EMTs, hospital administrators,
rural health officials, emergency preparedness representatives,
EMS agency managers, and EMS training coordinators. REMSTTAC again
provided the printed material and CD-ROMs to allow as much time
as possible for participants to discuss the issues.
The most pressing challenges and barriers
in the Appalachia area were:
Recruitment and Retention |
Funding |
Training |
Advocacy |
Equipment Costs/Needs |
Volunteers |
Inequality in health care |
Communications |
Professional Image |
EMS Service Management |
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When asked to rank and prioritize the top three
challenges from the above list, participants in all four locations
ranked: 1) recruitment and retention 2) training and 3) professional
image.
This series of meetings was highly rated with
a cumulative modified Likert score of 4.93 for meeting personal
objectives and 4.96 for speaker presentations.
Findings
These meetings with rural and frontier EMS providers
and rural health representatives substantiate other reports and
publications concerning the challenging environment facing rural
EMS. The meetings also aided in contributing to dialogue between
State offices of rural health and EMS agencies on the challenges
of rural EMS. Evaluation comments indicated that rural EMS providers
were unaware of the technical assistance and support that rural
health offices could provide to their agencies. State offices of
rural health also offered to support REMSTTAC activities at these
meetings.
Five main challenges were identified by the participants across
all venues. The items that were of greatest concern included: recruitment
and retention, funding/resources, advocacy, training, and professional/self
image.
1. A 2 year project funded by
the National Highway Traffic Safety Administration contractor
through a contract with the University of California at San Francisco
to describe the state of the current EMS Workforce.
2. In conjunction with the meeting
conducted at the West Virginia University, connections were established
with three other sites via televideo. The use of this technology
allowed the REMSTTAC staff to solicit more ideas and discussion
as well as allowing the participants to interact from distance
in real time. Evaluation results from the televideo sites reported
a mean of 4.82 and 4.93 for overall meeting personal objectives
and speakers presentations respectfully, which was slightly less
than the actual physical site visits. Personal objectives being
met had a mean of 4.93 and speaker presentations reported a mean
of 4.96.
DISCUSSION
Funding/Resources
In rural EMS systems, call volumes are low.
However, these services still need the same basic equipment and
supplies as higher volume services, thus-contributing to a high
cost of readiness. The cost of readiness can be particularly high
in those rural communities that choose to maintain higher levels
of prehospital care personnel (e.g. EMT-Paramedics rather than EMT-Basic).
Rural EMS also finds itself steered by other changes in health care
delivery systems. Some rural hospitals have closed in recent years,
and others have converted to Critical Access Hospitals, which has
affected the costs to EMS because of more frequent, and often longer,
interfacility transport times. Medicare and Medicaid reimbursements
and low collection rates have affected the financial status of EMS
(this was noted as particularly problematic in New England). Payment
for EMS services frequently do not cover the full costs of the services
performed. EMS faces funding challenges from reimbursement sources
at all levels: Federal, State, and local. Even in the aftermath
of 9/11 and the creation of a number of new grant programs to support
emergency preparedness, the funds appropriated towards EMS preparedness
activities have been limited.
Advocacy
It was noted that EMS lacks a consistent
voice on all levels - Federal, State, and local. In particular,
EMS needs a more consistent voice among State legislatures. Organizations
need to advocate, at the State level, for EMS needs. Many individuals
expressed concern that EMS has limited professional representation
and is not recognized as a profession, making it very different
from public health or fire departments. Participants also strongly
agreed that public information and education are critical to engendering
long-term support. They agreed that communities need to develop
a greater understanding of the EMS system, and in particular the
understanding of expectations relative to the costs of providing
services. It was generally felt that most of the general public
develops an "understanding" of EMS from television series
that are based in urban settings, with paramedics attending to the
sick and injured only minutes from a University Hospital or Level
1 Trauma Center and with state-of-the art clinical and communication
equipment. This may create unrealistic expectations in rural areas
that may rely solely on basic equipment, training, and other resources.
Recruitment and Retention
Since its inception, rural EMS has depended on
donated hours from community members who volunteer their time to
be part of the ambulance service. These individuals often pay for
their own training, certification, recertification, and medical
care (vaccinations, physical examinations) and are required to be
serving as an active member of a local ambulance service. Across
all three regional venues, it was noted that the volunteer pool
is shrinking. Many felt that society is not instilling individuals
with a commitment to give back to the community. Another frequently
cited opinion was that the EMS volunteers often disengage from their
volunteer commitments, at least in part, because of what is referred
to as the "sandwich" generation -- a generation of adults
who have responsibility for taking care of both their children and
aging parents. Others felt that EMS is no longer attracting an appropriate
pool of volunteers. EMS for years has been geared towards young
men, and in particular, those who enjoy the adrenaline rush associated
with a "red light and siren" response. Many felt that
EMS needs to present a more realistic face to recruits because once
they begin to serve they find that "it is a far cry from what
is on TV." Still others expressed opinions that rural EMS is
the training ground for urban systems or is utilized as a stepping
stone to better paying positions such as a physician's assistant
or a nurse. Once the community and EMS service have incurred the
cost to train an individual for field-work, they leave for a paid
position. These paid positions also have added benefits that EMS
could not afford to offer such as health insurance, paid vacation,
sick leave, and retirement plans. Many participants felt that there
is a real need for EMS to offer greater levels of recognition to
those who have served, and continue to serve, their communities,
in order to encourage retention. It was noted that many times, however,
the problem is simply "burnout." When both adult members
of a household work and face today's combined social, educational,
and economics pressures, there may not be enough time, energy, and
resources to become or stay involved with EMS volunteer work.
The effect of an aging rural population was also
of great concern. An aging population increases call volume, while
at the same time contributing to the shrinking volunteer pool. In
areas where 100 percent of EMS providers are volunteers, "this
graying trend can only spell disaster." Some areas in Appalachia
reported having resident populations where 80 percent or more of
the people are over the age of 60 years. Many expressed a need for
help with a community assessment to better educate the public and
help establishing a long-term plan that describes how EMS will be
provided. In some areas of West Virginia, the welfare system was
reported as the primary source of income in the area. In this environment,
tools must be provided to ambulance services to help retain personnel
already in the system and to recruit additional personnel. More
than anything else, many expressed the need for good management
by agency leaders, many of whom lack formal training in this aspect
of system leadership. One respondent noted, "Without this element,
nothing will improve."
Training
EMS providers are required to recertify every
2 to 3 years. This requires many hours of instruction. Many rural
volunteers expressed concern that they cannot afford the cost of
this process. Interestingly, there was a wide variance of opinion
between the need to "reduce" or "increase" training
requirements, but a general consensus emerged that the cost of training
needed to be offset in some fashion. Discussion about the need to
reduce or offset training costs invariably was followed by dialogue
regarding distance learning or the use of materials like CD-ROMs.
Many felt that distance learning was the wave of the future for
educating rural EMS providers. However, it was noted that in distance
learning the social aspects of local squad training are lost. Additional
questions arose about how to ensure EMTs achieved competence as
a result of distributive learning and who would be responsible for
monitoring and administering credits for completion. Others stated
concerns about whether distance learning techniques would "sacrifice
quality of education for quantity of education." It was noted
that in many rural areas access to, and speed of, the Internet is
still questionable, creating barriers to learning via distance education
modalities.
Professionalism, Self Image
Some participants felt that the image of an EMT
is still that of a hearse driver, who has graduated to ambulance
driver, and, to some extent, has not progressed any further. TV
has both helped and hindered in this regard. Television may have
promoted the image of EMT-Paramedics, but the public knows little
about the EMT-B, who is the dominant provider of prehospital care
in much of rural America.
Participants felt that EMS needs to educate the
public. EMS needs to be recognized as a profession, just as is firefighting,
nursing and many other healthcare disciplines. Many felt an image
change alone would help increase resources for EMS providers.
However, many felt that in order for EMS to undergo
a broad-scale transformation in image, EMS will need to change from
within. "We need to do background checks on individuals applying
to work with EMS. EMS needs to write better job descriptions, and
test for physical fitness and agility. EMS needs to stop simply
accepting anyone who volunteers and be more selective." Some
expressed an opinion that pervasive volunteerism has hurt the image
of EMS.
Although the Town Hall meeting findings
reinforce the conclusions in the Rural and Frontier Agenda for
the Future and the IOM's Future of Emergency Care reports,
a different conversation thread concerning EMT standards emerged.
The general consensus of the collective "group" was that
current standards were often too lax and that EMS needed to address
professionalism within its own ranks. Participants felt that before
a community's citizens, nurses, physicians, and others will assist
in addressing the needs of their EMS agency, the agency needed to
address the standards that they portray within their community.
CONCLUSION
The majority of time in each of the meetings was
spent discussing the need to identify new funding and resources
for EMS. The concept of a technical assistance center for rural
EMS was overwhelmingly confirmed as one of the directions that would
help with the continued success of rural and frontier EMS. At the
presentation of findings to the New England EMS Council, participants
agreed that comments from individuals in the field validated many
ORHP and REMSTTAC programs and initiatives that are underway.
REFERENCES
Institute of Medicine of the National
Academies, Future of Emergency Care Series. (2006). [Prepublication
Copy: Uncorrected Proofs]. Emergency Medical Services: At the Crossroads.
Washington, DC: The National Academies Press.
McGinnis, K.K. (2004). Rural and
Frontier EMS Agenda for the Future. Kansas City, MO: National Rural
Health Association.
APPENDIX A:
ACKNOWLEDGEMENTS
The Rural and Frontier EMS Town Hall Meeting Summary
document was made possible by funds provided by ORHP and the Rural
Emergency Medical Services and Trauma Technical Assistance Center
(REMSTTAC), the West Virginia University - Center for Rural Emergency
Medicine (CREM), and the University of Vermont - Initiative for
Rural EMS. Special thanks for producing this compendium go to the
Town Hall Workgroup and to REMSTTAC staff Heather Soucy, Program
Support Specialist.
Teri L. Sanddal, B.S., Co-chair
Associate Director
Rural Emergency Medical Services and Trauma Technical Assistance
Center
Patrick Malone, Director, Co-chair (2005)
Initiative for Rural Emergency Medical Services
University of Vermont
Dan Summers, Director of Education, Co-chair (2006)
Center for Rural Emergency Medicine
West Virginia University
Contributors and Reviewers:
Thomas J. Esposito, MD, MPH, FACS
Medical Director, REMSTTAC
Professor & Chief Section of Trauma Surgery
Department of Surgery
Loyola University Medical Center
Jacob L. Rueda III, Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
Nels D. Sanddal, MS, REMT-B
Director
Rural Emergency Medical Services
and Trauma Technical Assistance Center
APPENDIX
B: REMSTTAC STAKEHOLDERS GROUP
Katrina Altenhofen, MPH, REMT-B
State Coordinator
Emergency Medical Services of for Children
Iowa Department of Public Health
Jane W. Ball, RN, DrPH
Executive Director (Retired)
EMSC National Resource Center
Trauma-EMS Technical Assistance Center
Bethany Cummings, DO
Rural Affairs Ad Hoc Committee
National Association of EMS Physicians
Drew Dawson, Chief, EMS Division
National Highway Traffic Safety Administration
Tom Esposito, MD
Medical Director
Rural EMS and Trauma Technical Assistance Center
Blanca Fuertes, Past Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
Christian L. Hanna, MPH
Michigan Public Health Institute
Child and Adolescent Health
Bob Heath, EMS Education Coordinator
Nevada State Health Division
Intermountain Regional EMS for Children Coordinating Council
Marilyn Jarvis
Assistant Director for Continuing
Education
Extended University
Montana State University
Douglas F. Kupas, MD
Rural Affairs Ad Hoc Committee
National Association of EMS Physicians
Fergus Laughridge, Program Manager
Nevada State Health Division
EMS Bureau of Licensure & Certification
Tami Lichtenberg, Program Manager
Technical Assistance and Services Center
Rural Health Resource Center
Tommy Loyacono, MPA
National Association of Emergency Medical Technicians
Patrick Malone, Director
Initiative for Rural Emergency Medical Services
University of Vermont
N. Clay Mann, PhD, MS
Center Director of Research
Professor of Pediatrics
Intermountain Injury Control Research Center
University of Utah
Evan Mayfield, MS
U.S. Department of Health and Human Services
Center for Disease Control
Office of the Commissioner
Charity G. Moore, PhD
Research Assistant Professor
Cecil G. Sheps Center for Health Services Research
Univ. of North Carolina at Chapel Hill
Carol Miller, Executive Director
National Center for Frontier Communities
Kimberly K. Obbink, M.Ed, Director
Extended University
Montana State University
Jerry Overton, Executive Director
Richmond Amublance Authority
Daniel Patterson, PhD
AHRQ-NRSA Post-Doctoral Research Fellow
Cecil G. Sheps Center for Health Services Research
Univ. of North Carolina at Chapel Hill
Davis Patterson, PhD, Research Scientist
Battelle Centers for Public Health Research and Evaluation
Ana Maria Puente, Past Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
International Health / Office of Rural Health Policy
Jacob L. Rueda III, PhD, Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
Kristine Sande, Project Director
Rural Assistance Center
University of North Dakota Center for Rural Health
Mary Sheridan, Director
State Offices of Rural Health
Idaho Department of Health and Welfare
Dan Summers, RN, BSN, CEN, EMT-P
Director of Education
Center for Rural Emergency Medicine
West Virginia University
Chris Tilden, PhD, Director
Kansas Department of Health & Environment
Office of Local & Rural Health
Robert K. Waddell II
Secretary /Treasurer
National Association of EMS Educators
Bill White, President
National Native American EMS Association
Gary Wingrove, Technical Consultant
Technical Assistance and Services Center
Rural Health Resource Center
Jill Zabel Myers, Healthcare Consulting
Wipfli LLP
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