Saving Money the Rural EMS Way

What rural EMS services can teach the big guys

Increased costs and decreased funding are creating havoc in EMS agencies. Rising fuel, medical supply and equipment costs compete with escalating health insurance premiums for dwindling resources. Training budgets have been slashed. At the same time, communities expect more from their emergency services. It isn’t enough to respond to cardiac arrests, illnesses and motor vehicle crashes. EMS providers must be trained and equipped to handle a variety of natural and man-made hazards, including terrorism.


Making the most of limited resources is a lesson rural providers learned a long time ago. Perennially underfunded, these responders have been forced to develop innovative ways to provide the critical response the community requires while being good stewards of taxpayer dollars.


In his career as an EMS provider, Troy Hagen has been in the unique position to observe firsthand the challenges faced by rural services. Beginning his career as a volunteer firefighter in South Dakota, Hagen served as a reserve deputy sheriff, field paramedic, technical rescue team commander and supervisor. He is now the director of Ada County (Idaho) Paramedics.


Last year, Ada County Paramedics responded to more than 21,000 calls from 12 stations in a 1,060 square mile service area that includes Boise and surrounding rural communities.


Hagen knows that when faced with serious budget challenges, rural EMS has been able to not only survive, but continue to serve as a critical component in the healthcare infrastructure for millions of Americans. Perhaps there are some lessons the larger agencies can learn from these scrappy providers.


Although it may be easy for larger systems to create outreach programs and special operations teams, smaller agencies must remain laser-focused on the primary mission to survive. “When you’re a small agency, you don’t have time for confusion of mission or scope,” Hagen says.


“I’m a huge advocate of regionalization,” he says. “That’s how rural EMS lives day to day.” Whether big or small, a single agency that tries to do everything on its own is wasting money. “It’s not just the cost of doing EMS or rescue. Every agency has to have some level of overhead. It’s a significant amount of money,” he says.


By trying to do everything, Hagen is concerned that some agencies are spreading themselves too thin and becoming a master of none. One solution is to implement a variation on regionalization–partnering with neighboring agencies to work as a system. In a system, each agency decides who will be the expert in a given area. Perhaps one agency is the ALS provider for all three, while another specializes in rescue and the third in preparedness. Critically, they must all be really good at first response. By working together as a system, they not only better serve all three communities, but also save money.


“We have to decide to do what’s right for the community,” Hagen says. Sometimes, it’s difficult for leaders to get past a feeling of territorialism. “That’s not a rural or urban issue. That’s an emergency services issue,” he says.


Hagen admits that regionalization has some drawbacks. It’s harder to make changes in a regional system. Where it might have taken a week for a small agency to change a standing order, for example, it could take six months for a regional system. Still Hagen believes the benefits outweigh the downside.


Some more progressive rural systems are partnering with local hospitals. EMS volunteers spend part of their shift at the emergency department between calls, building competencies and establishing a close relationship for a seamless continuum of care.

Other money-saving tips

Because rural communities don’t have the money to buy pretty new toys whenever they wish, they have learned to use every piece of equipment to its fullest extent. “They don’t get rid of it until they are pushing it down the road,” Hagen says. It doesn’t matter how old it is or what it looks like as long as it runs. For the most part, that’s a concept their citizens can appreciate. Older equipment often gets repurposed as special rescue vehicles or disaster vans.


Paying attention to public relations and building community trust is an important lesson larger agencies can learn from their rural brothers and sisters. In a rural community, it’s not uncommon for the person on the ambulance to also be a city council member. Volunteers are active and visible members of the community. The larger the area, the less practical it becomes, but Hagen says that establishing those relationships can help keep a minor issue from becoming a major crisis.


Of course, public trust is a double-edged sword, Hagen warns. “It can swing very rapidly in a rural area,” he says. Maintaining those relationships takes constant vigilance. Marketing efforts are sometimes the first budget item cut in a down economy, but Hagen says this is no time to distance yourself from your citizens.


Hagen believes that keeping members engaged is vital. He admits it’s easier in a smaller agency. Typically, volunteers want to serve their community. “They’re vested with their hearts, minds and souls,” he says. Once a provider gets paid, they may begin to look at their job as a paycheck. To reengage providers, Hagen recommends doing things that build community and camaraderie, such as hosting a barbeque, a fundraiser or continuing education meetings.


Technology, such as social networking sites, can be helpful in creating communities where getting people together in a physical location is difficult. Regardless of the method, the key is to be persistent. “It’s an ongoing effort. Eventually, it becomes a culture,” he says.


In Ada County, Hagen helped establish a Journal Club. To help offset the cost, the club is sponsored by the local emergency physician group. The Journal Club meets quarterly to discuss current research and, occasionally, brings in guest speakers. Hagen says the free dinner doesn’t hurt attendance. Twenty people showed up for the first meeting. That number has increased as word has spread.


Instead of creating something from the top down, Hagen suggests finding out what people value. What’s valuable to a volunteer may not be to a career provider. “Everyone wants something different,” he says. “But you don’t know unless you engage your people.”


As funding sources dry up and costs continue to climb, every EMS agency, regardless of size, must be looking for ways to provide quality service for less money. Hagen admits that working under a tight budget isn’t always easy or fun, but it’s doable.

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