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Setup Instructions |
| Rural
and Frontier EMS Agenda for the Future: A Service Chief's Guide to Creating Community Support of Excellence in EMS 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. Printer-Friendly Acrobat Version (385 kb) Contents Community Assessment and Planning
Integration and Regionalization
Quality and Performance Improvement
APPENDIX A: About the Rural & Frontier EMS Agenda for the Future APPENDIX C: REMSTTAC Stakeholders The Rural and Frontier EMS Agenda for the Future, published in 2004, was a landmark document that focused attention on the issues specific to the survival and improvement of EMS in rural America. Much of what is included in the document is aimed at policy makers at various levels of government. However, it also contains many practical ideas and concepts that can, and should, be implemented at the local EMS agency level. This serves as a companion document to the report
and identifies some of the tasks that can be started in almost any
rural and frontier EMS agency. We recognize that taking on additional
tasks as a volunteer overseeing a rural agency may seem impossible.
However, the action items listed in each section are, in most cases,
small steps that can be accomplished over time.
Rural and Frontier EMS Agenda for the Future: A Service Chief's Guide to Creating Community Support of Excellence in EMS INTRODUCTION "Rural America is unique and requires unique
solutions." Ensuring access to high-quality EMS services is growing more and more difficult for EMS ambulance agencies in rural areas around the country. Many rural EMS agencies are finding that it is:
In order to succeed in the future, rural EMS agencies must galvanize community support, develop strong partnerships and collaboration, and utilize new systems to measure performance and enhance quality. Achieving any of these goals is difficult; succeeding in all three areas seems like an overwhelming task. However, there are resources to help rural EMS agencies address these challenges. One such resource is the recently published report, the Rural and Frontier EMS Agenda for the Future. This guide summarizes some of the key elements of the Rural and Frontier EMS Agenda for the Future, and describes the changing health care environment so that rural EMS services can best position themselves to succeed in the future. What is the Rural and Frontier EMS Agenda for the Future? The Rural and Frontier EMS Agenda for the Future is a 2004 report that describes an optimal future for rural EMS and describes changes that would be required for rural EMS to achieve that vision. Several associations worked together to complete the report and invited hundreds of EMS professionals and other interested people to submit comments regarding the current rural EMS system, and to suggest important systems changes that must occur for rural EMS to remain viable. The partner organizations that decided to undertake the project were the National Association of State EMS Officials, the National Organization of State Offices of Rural Health, and the National Rural Health Association. With funding from the U.S. Department of Health and Human Services Health Resources and Services Administration, Office of Rural Health Policy, these organizations set up a Web site to accept comments from any interested parties and also sponsored a 1-day meeting that was attended by over 100 individuals who represented ambulance services, other health care providers, and numerous associations and government agencies. A final report was published in October of 2004 (read more about the development of the "Agenda" Appendix A). The partners had several purposes when they decided to undertake this project. First, they wanted to lay out a policy agenda for political leaders and rural EMS advocates. They wanted to provide guidance to influence policy makers whose decisions can have an impact on the future of rural EMS. However, the partners also believed that the Rural and Frontier EMS Agenda for the Future could serve as a guide for local and State EMS agencies, and their communities, in developing realistic plans for the future based on available resources. Ultimately, sound local decision-making will ensure the ongoing success of EMS in any community. With that in mind, A Service Chief's Guide to Creating Community Support of Excellence serves as a companion document to the Rural and Frontier EMS Agenda for the Future and is created specifically to provide information, tools and resources to rural EMS leaders and their partners. Specifically, this guide will help EMS agencies address issues around the topics of:
This guide provides information about existing resources and tools that are available to local EMS leaders who undertake community planning and establish strong QI/PI efforts. The information is designed to help keep rural EMS services viable next year and well into the future. To survive, however, there is another important role for rural EMS, and that is the role of advocacy. An unfortunate byproduct of the lack of understanding of rural EMS is that oftentimes it is overlooked when policy decisions are made, or poor policy decisions are made on behalf of rural services. It is important that rural EMS be a strong and vocal advocate, and to educate the general public and policy makers at a local, State, and national level about the importance of a quality EMS system in rural areas. In this guide you will find information that will help you, as a local EMS leader, use strategies and techniques to advocate on behalf of your system. The remainder of this guide is broken into the three general focus areas summarized above: community assessment and planning, integration and regionalization, and quality and performance improvement. Each of the three sections is further broken down into three discrete parts, an introduction and background statement, a list of specific key associated recommendations from the Rural and Frontier EMS Agenda for the Future that support the section, and a brief list of specific action items that might be implemented to move a rural EMS system closer to the attainment of at least some of Rural and Frontier EMS Agenda for the Future's recommendations. Many rural EMS agencies will have already completed some of the tasks. Target those tasks and activities that make the most sense for your service. There is also a brief guide to advocacy at the end of this document. Advocacy is the word used to describe involvement of an agency in the political process. To be successful you have to do more than simply go about your business and provide good service; it is also imperative that you work with decision-makers to help them understand rural EMS needs and issues. This advocacy guide will provide some ideas about ways to get involved in the political process (see Appendix B). That process may seem intimidating or even mysterious to some. If you are among those, don't worry. This guide will take away some of that mystery and show you some simple ways to get involved, and help position your service for success. COMMUNITY ASSESSMENT AND PLANNING
Comprehensive advanced life support (ALS) services are difficult to establish and maintain in systems with low call volumes, because of the high fixed costs associated with ALS services and the challenge of being able to recruit, retain, and adequately reimburse highly-trained paramedics. As a result, the more remote a rural area, the less likely one is to find advanced life support (ALS) levels of EMS available in that area. However, even in rural areas many residents may expect that ALS care is readily available. In areas where EMS is heavily dependent on volunteers, and services are limited to basic life support (BLS), the general public may be surprised to learn that paramedic care is unavailable. In rural areas, many of which have a limited (and perhaps shrinking) resource base, community support of EMS should not be taken for granted. If EMS is to sustain community support, it is critical that the community understand the challenges EMS faces. Rather than shying away from community scrutiny, EMS should help communities accurately understand the services they provide, other service options that exist, and the cost of the options. This education needs to start at a basic level. Indeed, many people outside of health care do not even realize that different types of EMTs (basic, intermediate, and paramedic) exist. The community needs to understand the costs of maintaining EMS in both financial and human resources so they can make an informed decision about the level of service that is possible. Rural EMS services should promote a community-based EMS assessment and planning process and encourage community decision makers to determine the type and level of EMS they desire and the means to fund the system. You need to ask, "How can we add value to our present system?" A number of community EMS assessment and planning programs have been developed for rural areas in the United States. Two State EMS offices have developed community technical assistance team processes, and in these States expert teams visit communities to assist in the process of community assessment. Another process was developed by a not-for-profit agency with funding support from the Federal Office of Rural Health Policy. The Critical Illness and Trauma Foundation (Bozeman, Montana) offers their "EMS Community Planning and Integration Guide" online at http://www.citmt.org/Training.htm#Community%20Planning. This process includes a system self-assessment as well as perception surveys conducted with a variety of community sectors (health care, public safety, school system, media, government, etc.). Regardless of the approach you decide on, you will probably need some outside help. Your EMS Office, State Office of Rural Health or the Rural EMS and Trauma Technical Assistance Center (REMSTTAC) may be able to help you find resources to provide assistance with the assessment process. Key Recommendations from the Rural & Frontier EMS Agenda for the Future
INTEGRATION AND REGIONALIZATION
In many rural areas populations are aging. Older populations mean that the need for all types of health care services increases. However, at the same time many rural communities are finding it hard to maintain current health care services because of declining rates of reimbursement, challenges in recruiting and retaining health care professionals, and a declining tax base as a result of shrinking population. As other resources dwindle, communities may increasingly call on EMS providers not only for traditional emergency services but also for a range of informal care, evaluation, and advice. These services are often provided in "no transport" situations, which may be the reason that isolated communities often have "no transport" rates much higher than the State average. These locally developed solutions to fill a gap in the community's health needs have been called "EMS-based community health services" or "community paramedicine." In some cases these "no transport models" of care may impose additional burden on rural and frontier EMS systems due to loss of revenue. In other cases such care models may provide opportunities to bolster human resources by establishing paid positions at local hospitals. How can rural EMS respond to this growing demand for both traditional and non-traditional EMS services? Many experts believe the key to rural EMS' survival and success will depend on the ability of EMS providers to successfully link with partners including nearby EMS providers, local public safety, and especially the health care system. EMS should be able to draw upon fire department, emergency management, law enforcement, and public works resources (as well as resources from nearby EMS) as needed, based on the presence of mutual aid agreements. If such agreements are not in place, EMS agencies should contact their State Bioterrorism Hospital Preparedness Program (BHPP) or their Department of Emergency Management for assistance. Each State has a BHPP, funded through the Health Resources and Services Administration, and each State program is tasked with providing technical assistance to local EMS to develop such mutual aid agreements. Information is available at http://www.hrsa.gov/bioterrorism/. Rural and frontier EMS should also work closely with medical oversight to ensure that they are part of teams representing the continuum of care to enhance triage, transport and treatment decisions that make effective use of local resources and ensure a disposition in the patient's best interest. Many States have State trauma programs and within those programs, regional trauma teams or councils exist that work to enhance trauma care in their regions. Other local and State teams are working to enhance the continuum of care for stroke, heart attack, and other acute medical conditions that require emergency treatment. Sources of information on these programs are State Quality Improvement Organizations (http://www.cms.hhs.gov/QualityImprovementOrgs/) or State FLEX programs (http://tasc.ruralhealth.hrsa.gov/). Strong medical oversight is a key part of the development of such initiatives. However, little formal training exists for rural practitioners who are often trained in family practice or general internal medicine, to become well versed in providing medical direction for EMS. Currently, a collaboration led by the Critical Illness and Trauma Foundation is migrating the NHTSA medical director training program to an interactive Web-based format (http://www.citmt.org/training.htm). Regional approaches to consider are many. The most common regional cooperatives are Quality Improvement-based systems. In Kansas, the State FLEX program has funded the development of three such regional QI initiatives. In each case, a regional EMS provider has worked with smaller EMS agencies in the area to develop a common run form and to collect and analyze run form data from these agencies. The regional agency then brings all participating EMS units together on a regular basis to share information, explore best practices in care among the sharing agencies, and promote adoption of these best practices region-wide. EMS should involve emergency department and other hospital personnel in this process, as they may have valuable insight into the quality of care based on their observations of EMS when they arrive with a transported patient. In some cases EMS services have partnered with local physicians, and together they have worked with specialists in regional referral centers to develop standard protocols among the specialists in the referral centers. EMS agencies in a region may also wish to form a collaboration to pursue a joint purchasing arrangement that will allow them to purchase equipment and supplies at lower prices, and to rotate stock regionally to ensure that supplies do not have to be discarded due to non-use prior to expiration dates. One example of such a buying co-op is the North Central EMS Cooperative (NCEMC), another network: the Western EMS Network (WEMSN) is forming to similarly serve western States. State EMS offices (www.nasemso.org) and State Offices of Rural Health (www.nosorh.org) are places to search for information on such programs. Formalized agreements between nearby EMS services may also allow the integration of paid staff into units that have essentially relied on volunteer service. It may seem like a stretch for small basic life support (BLS) units to consider moving to a model that includes paid staff. However, the nature of volunteerism is changing in rural America. It is becoming more difficult to recruit young volunteers who themselves are willing to spend time away from their jobs, families, and other pursuits to volunteer for the demanding job of EMT. Finding volunteer staff to work during standard business hours can prove very difficult, as employers can be reticent to allow employees to leave work when they realize that long transports to a distant medical center may mean that an employee is away from the job for hours at a time. There are examples of services that have brought paid staff into their organizations and created ALS systems in environments that historically were based on BLS services. However, this usually entails integration of several local EMS units, a political and operational process that is, admittedly, very difficult to achieve. We are not suggesting that an ALS system is needed in each area. That decision should be part of the community planning process described in the first section and supported by historical EMS response data. A well-trained BLS system with strong relationships to area health care organizations may be the right solution for many rural areas, but even these systems will likely need to move toward a model with paid staff. This goal might also be accomplished through integration of EMS and a local hospital, another process that might sound intimidating...to both sides! Different cultures among EMS and hospitals has often meant that there is an important, yet uneasy, relationship between the two. However, integration can have important benefits. Integration may be defined as close collaboration or sharing of resources. Integration can provide services access to new resources. Integration provides EMTs the chance to work in other prehospital and in-hospital settings. Another potential benefit is the chance to generate new revenues for the ambulance service. For example, some EMS units owned and operated by Critical Access Hospitals receive cost-based reimbursement for Medicare and Medicaid patients. Analyses have shown that cost-based reimbursement for emergency services can result in significant additional Medicare and Medicaid revenue. For more information about cost-based reimbursement, contact your State FLEX program. State program contacts for the FLEX program can be found at http://tasc.ruralhealth.hrsa.gov/. Key Recommendations from the Rural & Frontier EMS Agenda for the Future
QUALITY AND PERFORMANCE IMPROVEMENT
It is true that public expectations of EMS are high. Often times in rural areas, the expectations may be unrealistic. But EMS providers, whether individual prehospital care providers (EMT-B, EMT-I, EMT-P) or the service providers themselves, are all interested in meeting expectations, and in helping to the best of their abilities. Also, it must be stated that high quality prehospital care does not relate to the level of care provided (ALS & BLS). Basic life support services can provide high quality care. EMS providers do strive to continuously improve the quality of services they provide to their patients and to enhance their overall system performance. It is central to the mission of EMS to provide the best care possible. However, traditional methods used within health care and sometimes in EMS to enhance quality (often referred to as "quality assurance") are limited in their ability to truly make advances in improving the quality of services delivered. It is thus important for EMS to begin to adopt new methods to enhance quality. It is something patients will expect and demand, and in the future, the ability of EMS providers to document the quality of care they provide may influence their levels of reimbursement. Purchasers of care, like the Medicare program, have already begun basing payments to some types of health care providers on the basis of "pay for performance." In such systems, providers must demonstrate their involvement in Quality Improvement (QI) efforts, or even demonstrate actual improvement in quality on the basis of some predefined set of measures. QI systems can be simple or complex. If your system
is just beginning a QI program, start simple. Determine several
areas where you believe your system could show improvement. Select
a clinical area, and perhaps also a non-clinical area (form completion,
recruitment progress, billing efficiency, etc.) and discuss the
issue. One way to generate these ideas is by creating a "benchmarking" system. This is accomplished when a group of health care providers agree to share information through a systematic process so that everyone in the group can see who does something particularly well. The group of providers agrees to measure the same process, and to share the resulting data amongst themselves. Providers that may be struggling with a particular activity can ask those services that seem to be doing well for advice and assistance, thus allowing everyone to benefit from this mutual effort. Several State Flex programs have used Federal funding to support the development of benchmarking systems. In Kansas, for instance, the Flex program provided start-up grants to three groups of ambulance services that came together to do benchmarking. In each instance, one ambulance service took the lead in discussions among a number of area EMS providers about creating a common run form, focusing on certain elements that were measured by the run form, and sharing the information among one another through reports and monthly meetings when the services got together to share lessons learned and "best practices." These networks also provided computers to each ambulance service so that they could enter the data into a computer, which made the comparisons among the services easier to accomplish. Another place to get ideas on performance improvement is from hospitals where you transport patients. Have you ever sought input from Emergency Department staff in the hospitals where you transport? They might be a valuable source of information. State Rural Hospital Flexibility Program (FLEX) programs are encouraged to support this type of integration and collaboration, so you should contact your State FLEX program to see if they may have resources or assistance that could help you develop this type of process. Of course, once a service has gathered ideas on ways to improve a process, they should implement those changes. It is ideal to implement one change at a time so you can measure the impact of the change. Implement one change and then continue to evaluate the issue, and after 1 or 2 months determine if the change made a difference. If it did, you might be satisfied with that and move on to look at other measures. Or perhaps you are still not satisfied and think you could enhance performance even more. Perhaps you institute another change and once again measure progress in that area of concern. Don't continue to evaluate the same parts of your service forever. Choose one or two areas and show that you can make improvements. Then move on to another area. Put together teams that can oversee the process. These teams can include internal staff, but as we discussed above, consider other resources - other ambulance services, hospital personnel, perhaps even community members (who represent the patient perspective). Of course, it is critical to involve the service medical director in this process. Resources for QI Project Development Of course, taking on QI projects takes time and resources. You may feel you don't have sufficient staff to take on this added responsibility. If that is the case, please realize there are many resources available to help you move forward. As mentioned before, FLEX programs often have (or are aware of) resources that can help develop these projects. There are also organizations in each State, funded by the Medicare program, to help health care providers develop QI programs. These organizations are known as Quality Improvement Organizations, or QIOs (find your QIO online at http://www.cms.hhs.gov/QualityImprovementOrgs/). Each State QIO is different, so your QIO may, or may not, have resources that are pertinent to EMS. You may also be able to identify volunteers within your communities who can help. A great recruiting tool is to provide opportunities for area youth to learn about EMS. Would you consider asking the local high school if they would like to offer an internship(s) to a student to help your service develop a QI program? Approaching a larger ambulance service in the area to see if they would be interested in helping with program development is another way to not only establish a QI program, but promote cooperation and regionalization as well. Many hospitals have well developed QI programs. Do you believe an area hospital might be willing to help you? You might find assistance from a small local hospital, or perhaps a tertiary facility further away. You may feel that you don't have a good working relationship with these facilities, but we urge you to take the step, to start talking with these hospitals. Caring for patients who arrive through the ER is of critical importance to hospitals, and they are very interested in working to ensure that the continuity of care from one provider to the next is as good as it can be. Your area hospitals, if they are like most, will be happy to begin talking with you about creating joint QI opportunities. For instance, a collaboration between area EMS, community hospitals and cardiac specialists in a referral center might come together to help determine how to improve the entire continuum of care for a heart attack patient who lives in your community, from the time he/she places a 9-1-1 call to the time they receive treatment in the tertiary facility. A project of this type was initiated by the Minneapolis Heart Hospital. Working with community ER physicians and area EMS providers, they were able to improve system "hand offs" and communication and significantly reduce the amount of time it took to get transported patients onto the operating table for life-saving angioplasty. Key Recommendations from the Rural & Frontier EMS Agenda for the Future
We hope that you have found this document useful and practical. Hopefully, it has stimulated your thinking about how your service might be improved or solidified, how you might better engage the public or how you might work with other agencies. We look forward to receiving your comments and thoughts on how we might improve this document in subsequent editions. Thank you for using the Rural and Frontier EMS Agenda for the Future: A Service Chief's Guide to Create Community Support of Excellence in EMS. We're interested in your feedback on the use and utility of this product. If you have comments or suggestions for improvement, please contact us at: Health Resources and Services Administration,
Office of Rural Health Policy REMSTTAC APPENDIX A: ABOUT THE Rural and Frontier EMS Agenda for the Future In 1996 the National Highway Traffic Safety Administration brought together a broad set of experts and advocates to create the EMS Agenda for the Future. This document was supposed to set out a broad vision for the future of EMS. However, because rural America presents such a unique set of challenges to the provision of Emergency Medical Services, the National Rural Health Association, the National Association of State EMS Directors, the National Organization of State Offices of Rural Health and the Federal Office of Rural Health Policy came together in 2003 and 2004 to target the national goals outlined in this report that were most critical to rural communities. These partner organizations were responsible for the publication of the Rural and Frontier EMS Agenda for the Future. Their goal was to inspire and inform a number of different audiences. For rural advocates it was to serve as a policy blueprint for the future. For political leaders, it was designed to outline what needs to be done, and what needs to be funded, to ensure that quality EMS care is available in even the most remote, frontier communities. And for rural communities nationwide, the partners hoped that the new document would serve as a tool for what communities could do with available resources and how they could plan to sustain and enhance EMS services in the future. The Rural and Frontier EMS Agenda for the Future was built on the same format as the 1996 EMS Agenda for the Future. It proposed continued development of 14 key EMS attributes:
A process for developing the document began in 2003. Volunteer writing and editorial teams helped in the direction of a draft document that was posted to the NRHA web site in fall 2003. From January to June of 2004 over 235 individuals from over 100 organizations provided comments about versions of the document that were routinely posted to the Web site. These included about 100 individuals including local ambulance directors, State EMS officials, State rural health officials, and a range of policy experts provided input during a 1-day session preceding the May 2005 National Rural Health Association Annual Rural Health Conference. The document was first released to the public in October 2004 at the annual meeting of the National Association of State EMS Directors (now the National Association of State EMS Officials). Fulfilling the vision identified in the Rural and Frontier EMS Agenda for the Future requires the application of significant Federal, States and local resources as well as committed leadership at all levels. Because significant policy and funding decisions at Federal and State levels are critical to future success of rural EMS, the Rural and Frontier EMS Agenda for the Future focused, in large part, on those policy makers. However, the project partners also recognize that action at the local level is just as important, if not more important, to the future of EMS in rural communities. We recognize that rural and frontier EMS providers are acutely aware of the challenges they face. As such, this new "Service Chief's Guide" has been created in hopes of arming local EMS providers with information about possible future directions for rural EMS system development to ensure their survival, advancement, and growth. It is meant to serve as a companion document to the Rural and Frontier EMS Agenda for the Future, and we encourage rural EMS leaders to learn about and use that original document. It is available for free download at http://www.citmt.org/download/rfemsagenda.pdf This service chief's guide was made possible by funds provided by ORHP and the Rural Emergency Medical Services and Trauma Technical Assistance Center (REMSTTAC) and the Kansas Department of Health and Environment. Special thanks for producing this guide go to Chris Tilden from the Kansas Department of Health and Environment, Office of Local and Rural Health and to REMSTTAC staff Nels Sanddal, Director; Heather Soucy, Program Support Specialist; Joe Hansen, Assistant Director and Teri Sanddal, Associate Director; and members of the Service Chief's Guide Workgroup at REMSTTAC. Nels D. Sanddal, B.S., Co-chair Chris Tilden, PhD, Co-chair Contributors and Reviewers: Dennis Berens Dean Cole D. Randy Kuykendall, MLS, NREMT-P Fergus Laughridge
Mary Sheridan Ron Seedorf APPENDIX C: REMSTTAC STAKEHOLDERS GROUP Jane Ball, Executive Director Eli Briggs, Policy and State Affairs Manager Bethany Cummings Drew Dawson, Chief, EMS Division Tom Esposito, Medical Director Blanca Fuertes, Past Project Officer Tommy Loyaconno, Representative Christian L. Hanna, Rural Site Director Bob Heath, EMS Education Coordinator Marilyn Jarvis, Assistant Director for Continuing
Education Doug Kupas Fergus Laughridge, Program Manager Patrick Malone, Director N. Clay Mann, Professor, Associate Director of
Research Evan Mayfield, CDC Public Health Advisor Charity Moore, Research Assistant Carol Miller, Executive Director Daniel Patterson, AHRQ-NRSA Post-Doctoral Research
Fellow Davis Patterson, Research Associate Ana Maria Puente, Project Officer Kristine Sande, Project Director Dan Summers, Director of Education Chris Tilden, Interim Director Robert K. Waddell II, Secretary /Treasurer Bill White, President Gary Wingrove, Program Development Jill Zabel, Healthcare Consulting |
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