Mobile Integrated Healthcare

Rural Texas EMS-Based Fire Agency Offers Unique Blend of Prehospital Training and MIH-CP

Issue 8 and Volume 41.

Bulverde Spring Branch (BSB) Fire & EMS is an emergency services system in rural Texas that sprang out of three separate agencies and has become a model for EMS-based fire services. The agency provides emergency services to a 216-square-mile area north of San Antonio. The agency’s mission statement is, “To respond immediately with educated professionals through pioneering science and technology, creating profound good.”

One benefit of its merged services comes from an observation made by one of their medics, who stated, “Before the consolidation of services, it was just me and my partner out there for 24 hours at a time. We felt isolated. Now that we have combined [the three agencies] and everyone has dual roles, I feel like we gained a family.”

Agency Unification

The three agencies that came together to form BSB Fire & EMS were:

  1. Spring Branch Fire/Rescue: The first emergency services organization in the Bulverde-Spring Branch area, founded in 1959. In rural Texas, the formation of volunteer fire departments wasn’t unusual and Spring Branch Fire/Rescue wasn’t alone.
  2. Bulverde Fire Department: Founded in 1966 for structure and brush firefighting, the founders also worked to form a rescue squad with medical capabilities in the formative years. Originally founded as the Bexar-Bulverde Volunteer Fire Department, it was split into two separate departments in 1986 to establish tax funds more effectively between the two counties.
  3. Bulverde Spring Branch EMS: Formed in 1978 after a 46-year-old man died of a heart attack and Bexar County (which includes the city of San Antonio) was unable to cross the county line and a local hospital was too far. Like both local fire departments, the agency had meager beginnings, transporting out of a converted station wagon.
Mobile integrated healthcare in Texas Fire-EMS system
Bulverde-Spring Branch EMS first transported patients in a converted station wagon in 1978, a stark contrast to today’s modern ambulances.

For all three agencies, financial struggles were always on the top of every meeting and strategic planning session. Maintaining a viable fire/EMS department, with up-to-date vehicles and highly trained personnel, was a serious challenge in rural Texas counties due to significant increases in the number of fire and EMS 9-1-1 calls that resulted from increases in population density and growth; traffic and motor vehicle crashes; and commercial and residential construction.

In 2014, the two fire departments agreed that to strengthen the daily operations and meet budget challenges, forming a single governance structure with EMS was the best answer. BSB Fire & EMS was created to manage the reorganized departments under the direction of a single agency led by CEO and President Mechelle Salmon.

A combined fire/EMS shield helped ensure cohesion of personnel and company pride and was incorporated into new uniforms and the rebranding of the agency’s 32 vehicles. This was rolled out expeditiously without a single delay in fire or medical response.


One of the hallmarks of the organization is the Centre for Emergency Health Sciences, a state-of-the-art training facility with a Texas State Anatomical Board-approved cadaver lab that allows healthcare professionals to learn and practice emergent procedures that are infrequently performed in a rural setting with limited call volumes, yet remain cornerstones in treatment.

Of note is the substantial and demonstrated difference between performing these critical procedures on manikins vs. cadavers. Although manikins provide applicable experience, they lack the skill refinement afforded by practicing the procedures on human cadavers.

Mobile integrated healthcare in Texas Fire-EMS system
The Centre for Emergency Health Sciences allows healthcare professionals to learn and practice emergent procedures that are infrequently performed in a rural setting with limited call volumes, yet remain cornerstones in treatment.

The Centre for Emergency Health Sciences affords medical school-quality programs to providers who would otherwise have little ability to locate or pay to hone these skills now required in the field. This includes a nationally recognized procedural anatomy course, focusing on emergent interventions and resuscitation, that offers hands-on experience with fresh and embalmed human specimens. It’s taught by a team of highly experienced medical professionals, including paramedics, nurses and physicians, who teach the most demanding procedures with appropriateness, skill and expertise.

In addition to provider training, BSB Fire & EMS offers a high school anatomy program and junior crew, which was initiated for young adults aged 14 to 20 as part of the Scouting Explorer Program, which introduces students to fire, EMS, police and medical careers.

The Centre for Emergency Health Services also boasts residency programs in emergency medicine, orthopedics and oncology in addition to hosting research scientists from around the world who engage in cutting-edge medical research for a variety of institutions, including the Department of Defense, law enforcement agencies, medical groups and the healthcare industry.


BSB Fire & EMS has robust mobile integrated healthcare/community paramedicine (MIH-CP) offerings, including identification and management of frequent system users via wellness checks, injury prevention visits, and other types of daily support. These frequent users are identified by agency personnel, who provide expertise on medical facility requests and social services; medical interventions; hospice revocation avoidance and hospital readmission avoidance. Hundreds of home visits enhance care in a rural community with limited healthcare resources.

The agency’s Wellness on Wheels (WOW) multifunction trailer provides mobile, patient-centered resources in the out-of-hospital environment and also plays a part in disaster response as a customized medical trailer that serves as a command center. EMS vehicles provide expanded healthcare services for home visits for recently discharged hospital patients and those with chronic medical needs. There are strategic community partnerships offering mental health, dental, vision and prescription services to the community’s medically underserved.

Mobile integrated healthcare in Texas Fire-EMS system
Wellness on Wheels (WOW) is a multifunction trailer that provides patient-centered,mobile resources in the out-of-hospital environment and also plays a part in disaster response.

WOW has participated in health fairs and mission trips to South Texas and the Texas-Mexico border regions. The mission trip was the first of many to the Colonias, an unincorporated area of South Texas with unregulated, substandard settlements and minimal to no water or sewage infrastructure.

WOW also hosts educational events for prehospital providers, schools and community groups, such as a recent Stop the Bleed campaign. The Comal County school district deployed over 800 tourniquets and bleeding kits in schools and the WOW was used by BSB Fire & EMS to train more than 20,000 high school students in more than 30 schools. The Special Operations Medical Association presented this training effort with a special recognition award.

Another component of the BSB Fire & EMS MIH-CP program is the Acacia Medical Clinic, a 501(c)3 nonprofit that provides medical services to the underserved in Comal County. Dedicated volunteers staff the clinic with on-duty crews at BSB Fire & EMS’ central station, participating in patient intake, initial patient assessment, procedures and discussion of management issues. The staff works with local social services and providers to enhance the reach beyond the agency’s limited funding. This allows both EMTs and paramedics to engage in discussion and education with the patient outside of an emergency environment. This interaction provides patients with a better understanding of chronic disease management and enables visualization of how noncompliance results in increased emergency calls. About 550 patients have been served. Originally staffed only one evening per week, it now operates two days per week.

In addition to volunteer staffing, much of the clinic’s medications are obtained via coordination with local physicians, whose offices donate excess supplies and samples. Portable laboratory testing is provided via a moderately complex-level Clinical Laboratory Improvement Amendments-compliant program.

These opportunities not only benefit patients, but also serve to expand the role of emergency response personnel and give them exposure to a different component of our healthcare system.

Ultimately, the goal of BSB Fire & EMS MIH-CP initiatives is to realize improved outcomes while reducing costs and improving quality of care. Let’s look at a specific example: a 64-year-old male who called 9-1-1 multiple times, resulting in12 transports in one year in addition to calls resulting in patient refusals and lift assists.

This patient has a significant medical history including: diabetes, alcoholism, tobacco use, chronic obstructive pulmonary disease (COPD), sinus tachycardia, palpitations, alcoholic fatty liver disease, syncope and hypertension. Community paramedics engaged in home visits, both as scheduled and nonscheduled interactions. He was also enrolled in Acacia Medical Clinic, allowing for regular provider visits.

Mobile integrated healthcare in Texas Fire-EMS system
BSB Fire & EMS largely focuses on the medical needs in its rural Texas service area but still provides expert fire suppression service that’s ready to respond as needed.

Through these visits and counseling sessions, the patient’s alcohol consumption decreased to a manageable level and his tobacco usage was cut in half. His COPD was diagnosed and appropriate inhalers were provided via a local pharmacy benefit program and patient assistance programs. Through a referral program with a local hospital, the clinic arranged for the patient to see a cardiologist, resulting in the resolution of his syncope and palpitations. Over the next four months, no calls to EMS were recorded and the patient continues to be followed in the clinic—a profound effect on one man’s life.

Funding for MIH-CP programs is provided directly and indirectly. The BSB Fire & EMS board of directors provides a combined budget of $136,000 to support MIH-CP. Local foundations also supported the initial implementation and growth of MIH-CP: The McKenna Foundation provided approximately $500,000 and the Kronkosky Charitable Foundation provided $75,000 for multiyear projects. These relationships are forged and fostered by a dedicated MIH-CP development director responsible for bringing in over a half-million dollars annually.

Other avenues of support include crowdsourcing via GoFundMe, which was used to obtain endoscopic procedures, regional hospital support, and requests to physician colleagues to care directly for orthopedic injuries for unfunded patients.

Measuring Success

When measuring success of MIH-CP programs, many agencies look to concrete numbers and financial spreadsheets showing the number of lives saved, transports avoided, etc. Given the fluidity and diversity of funding sources, it’s difficult to determine these metrics with our program.

One measure we use is comparing response times with a neighboring community outside the BSB Fire & EMS district. This area has a lower increase in housing growth, but has a 16% increase in emergency call volume compared to BSB Fire & EMS, which had only a 4% increase during the same period.

We directly attribute our smaller increase to our MIH-CP program. More importantly, we see the satisfaction of responders knowing they have an outlet for evaluating and treating chronic disease issues outside of the typical 9-1-1 response. This value shines through with the expressions of gratitude displayed by the patients our providers have cared for. These patients have no other means of assistance, and our programs and providers preserve their dignity and allow patients to remain within the community.


BSB Fire & EMS is a progressive agency that’s blossomed during its recent reorganization of fire services and EMS. Direction and leadership from the agency’s board of directors and administration has resulted in a dynamic organization that not only provides expert medical care and fire suppression but also is a demonstrated leader in medical education and community service.

Current principles of MIH-CP have been expanded upon to include not only core principles and metrics, such as reducing hospital readmissions, but also provided the community with a station-based mobile healthcare clinic and education center that expands the horizons of prehospital training for both agency personnel as well as members of our community.