The New EMS Imperative:

Demonstrating Value

In
STRATEGIES AND SOLUTIONS FOR LOCAL GOVERNMENT MANAGERS

VOLUME 47/NUMBER 1 2015

D espite a tremendous
diversity in how emergency
medical services (EMS) are provided
be required to demonstrate their worth like never
before. At the same time, municipalities continue
to confront the economic realities of stagnant and
in municipalities around the country, even shrinking budgets.
most U.S. EMS systems share one commonality:
They remain primarily focused on responding It’s critical for city and county managers to know
quickly to serious accidents and critical that despite these challenges, the changing health
emergencies even though patients increasingly care landscape also presents opportunities for EMS
call 911 for less severe or chronic health systems to evolve from a reactive to a proactive
problems. model of health care delivery—one that better
meets the needs of their communities by preventing
Simply put, the existing EMS response model unnecessary ambulance transports, reducing
has failed to evolve as community needs for emergency department visits, and providing better
emergent and nonemergent health care delivery care at a lower cost.
have changed. Recent efforts in health care to
improve quality and reduce costs, such as the This InFocus is intended as a guide to identify
Affordable Care Act, pose significant challenges challenges and opportunities, measure your
to the existing EMS response model. Health care efforts, and define success. This report explores
payers have become increasingly unwilling to how EMS systems can improve service in tough
reimburse for services that fail to prove their economic climates and navigate new challenges and
value. As a consequence, EMS agencies will soon opportunities presented by the Affordable Care Act.
The New EMS Imperative: Demonstrating Value

Current landscape in EMS

EMS treatment and transport
The standard model for treatment and transport of sick and injured persons by EMS sys-
tems has changed very little since the 1960s, when growing pressure to reduce highway
deaths and injuries prompted Congress to fund improvements in EMS systems across the
country.
While several types of EMS systems exist (See Table 1), most follow the same basic
response model. Call-takers and dispatchers obtain critical information and then summon
emergency responders to the scene. First responders provide basic medical care until an
ambulance arrives. Ambulance personnel then conduct a patient assessment and perform
any necessary interventions before transporting the patient to the hospital. If the patient
declines transport to the hospital, they are considered to have refused care against medi-
cal advice.
The EMS response model continues to emphasize emergency stabilization and rapid
transport to the hospital as the primary role of the EMS system. This is true despite
evidence that a significant proportion of 911 calls are for non-emergent medical condi-
tions that do not require immediate care and transport.1,2 And it ignores the fact that the
hospital emergency department is often neither the most appropriate, nor the most cost-

Joseph J. Fitch, PhD, is the founder and president of Fitch & Associates, a fire service
and ambulance consultancy based in Kansas City, Missouri. Dr. Fitch is internationally
recognized for leadership as a consultant, educator, and innovator in the fields of EMS and
public safety. He has written and spoken extensively, contributing hundreds of articles and
seminars to enhance the profession. He can be reached at [email protected].

Steve Knight, PhD, is a senior associate with Fitch & Associates. Dr. Knight served
nearly 17 years as the Assistant Fire Chief for the city of St. Petersburg, Florida. He has
been a subject matter expert for both the National Fire Academy and the Center for
Public Safety Excellence. Prior to joining Fitch & Associates, Dr. Knight was the senior
manager for Fire and EMS with the International City & County Management Association
(ICMA). He can be reached at [email protected].

Keith Griffiths is president of the RedFlash Group, a national consulting firm that
provides award-winning outreach and education for the health care and public safety
fields. Since 2000, RedFlash Group has served leading commercial firms, government
agencies, and national associations and foundations, as well as a select group of service
providers. He can be reached at [email protected].

Michael Gerber, MPH, an associate consultant with the RedFlash Group, started in EMS
in 2001 as a volunteer and later EMS supervisor in the fire service. He has experience
as an EMS educator, quality management coordinator, and operational officer. Gerber
worked as a staff writer for The Hill newspaper, reporting on Congress and the lobbying
industry, and has also been published in the Washington Post and Hartford Courant. He
can be reached at [email protected].

Contributors to this report include the following subject matter experts from Fitch &
Associates: Rick Keller, founding partner; Anthony Minge, MBA, partner; Guillermo
Fuentes, MBA, partner; and Mike Ward, MGA, FlFireE, senior associate. Mario J. Weber,
MPA, an associate consultant with the RedFlash Group, also contributed to the report.

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The New EMS Imperative: Demonstrating Value

effective, destination for patients. This is especially true for patients who are only seeking
routine medical care that would otherwise be provided in a physician’s office or other
non-emergent setting.
For local governments, the growing mismatch between the capabilities of existing
EMS systems and the demand from constituents for non-emergent but “unscheduled”
medical care represents a failure in service delivery. It also poses a problem of resource
utilization; EMS resources such as ambulances are increasingly unavailable for emergen-
cies while they transport non-emergent patients to the hospital. Innovative approaches to
EMS delivery are necessary to ensure that EMS systems remain aligned with community
needs.

Table 1: Types of EMS Systems

There are six common models for EMS delivery in the United States: fire service-
based, public utility, third government service, private for-profit, private non-profit, and
hospital-based.
Almost half of all EMS systems are based in fire departments. Depending on the system,
Fire department ambulances are staffed by “single-role” civilian EMS providers or “dual-
role” firefighter/EMTs, who also perform fire suppression functions.

The public utility model of EMS uses a separate governmental entity to manage emergency
medical services in a community, either with a private contractor or by providing the service
directly. Local government officials appoint leadership and also approve funding.

The third-service model provides for the delivery of EMS by a separate department within
the existing local government structure. This department exists alongside other public safety
departments (police and fire) and employs civilian EMS providers. Funding and day-to-day
operations, including support functions, are under the direct control of the local government.

Private for-profit provision of EMS is characterized by the contracting-out or franchising of

EMS to a for-profit provider. Service levels and performance can be specified in the contract
but the private contractor often has total control of operations.

The hospital-based model of EMS delivery is also defined by a contractual relationship,

in this case between a local government and a hospital (or a local entity associated with
a hospital). The hospital-based entity is often a non-profit and may require a government
subsidy. As in the private for-profit model, however, the local government has limited day-to-
day influence over operations.

In the private non-profit model, community-based or volunteer agencies provide emergency

medical services that are subsidized by a combination of government funding, donations, or
user fees. These organizations are self-governing and exercise complete control over day-
to-day operations. They may use volunteers, paid personnel, or a combination of the two to
staff ambulances.

Funding
EMS systems (whether public or private) receive very little in the way of federal or state
subsidies. Consequently, most EMS systems seek to offset a portion of their operating
costs by billing patients for transport to the hospital.3 This “fee-for-transport” funding

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The New EMS Imperative: Demonstrating Value

scheme is based on the federal government’s reimbursement model for Medicare and
Medicaid patients, which has also been adopted by most private payers.
Unfortunately, seeking reimbursement for transport to the hospital has proven insuf-
ficient to cover the costs associated with EMS delivery. Reimbursement rates for ambu-
lance transport of Medicare and Medicaid patients (who account for approximately 60%
of patients transported by EMS agencies) have consistently failed to match the cost of
service.4 The resulting shortfalls have been only partially subsidized by reimbursements
from private payers, as patients with private insurance account for less than a quarter of
patients transported to the hospital by EMS agencies.5
The current fee-for-transport model of EMS funding also does not adequately account
for the non-transport costs of EMS delivery, including the cost of medical care rendered
to patients by EMS providers, the cost of caring for patients who ultimately decline
ambulance transport to the hospital, and the “cost of readiness” associated with main-
taining the capability to quickly respond to medical emergencies on a 24/7 basis. The
result is that EMS agencies have a financial incentive to transport all patients to the hos-
pital regardless of medical necessity—even if only to recoup a small portion of the overall
costs associated with providing emergency medical services.
As a consequence, most local governments find themselves in the position of hav-
ing to directly subsidize their EMS system. This is the case even in communities where
ambulance transport is provided by private contractor. For local governments then, espe-
cially those still grappling with revenue shortfalls, the EMS system is yet another signifi-
cant cost to be managed—one that must be carefully aligned with the particular priorities
and needs of each community.

Challenges
How to demonstrate cost-effectiveness

Response times. EMS systems have often sought to demonstrate their effectiveness by
measuring the time it takes for a responding unit to arrive at the scene of an emergency.
Specifically, most urban systems have adopted a goal of 4 minutes for a basic life support
(BLS) unit to arrive at the scene and 8 minutes for an advanced life support (ALS) unit to
arrive.6
The origins of these response time goals can be found in early research on out-of-
hospital cardiac arrest, which showed an improvement in patient outcomes if CPR was
initiated within 4 minutes and defibrillation was delivered within 8 minutes.7 More recent
research, however, has called into question the value of using response times to measure
EMS system performance. Very short response times (4-5 minutes) may increase survival
for certain life-threatening conditions (such as cardiac arrest and allergic reactions), but
other differences in responses time (e.g., the difference between 6 and 10 minutes) likely
do not result in better patient outcomes.8 Consequently, each community’s response time
standards goals should reflect a careful balancing of medical necessity and community
expectations on the one hand, and community resources and attributes (e.g., urban vs.
rural) on the other.9
Two strategies for safely increasing response time standards in a community include:
• Allowing for longer ambulance response times if a first responder (often a basic life
support unit staffed by the fire department) is able to arrive within the first several
minutes and provide initial management and stabilization of a patient.
• Establishing different response time standards depending on the nature of the medical
emergency or the severity of the patient’s medical condition.

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The New EMS Imperative: Demonstrating Value

Unit hour utilization. EMS systems have also looked to measure productivity as a proxy
for system efficiency. One commonly used measure is unit hour utilization (UHU), a ratio
that is typically calculated by dividing the number of transports by the number of unit
hours.10 In other words, an ambulance that performs four transports in a 12-hour shift
has a UHU of 4/12, or 33%. However, some agencies will calculate UHU by using the
total number of hours that EMS units are engaged on calls by the total number of hours
that those units are staffed and fully-equipped. Neither method is right or wrong, and
each has advantages—an agency worried about recouping costs might want to focus on
transports, while an agency more concerned with staff performance and preparedness
levels would be more concerned with the percentage of time ambulances are available.
Unit hour utilization varies greatly among EMS systems, and there is no generally-
accepted consensus regarding the ideal ratio. EMS agencies responding solely to 911 calls
typically target a lower unit hour utilization (between 0.30 and 0.50 UHU) than non-
emergency ambulance transport providers—in order to ensure that a sufficient number
of units remain available to respond to emergency calls. Agencies whose providers work
longer shifts, such as 24 hours, also often aim for lower UHUs due to concerns over
fatigue and safety.
It is important to note that unit hour utilization traditionally does not capture produc-
tivity outside of responding to emergency calls, such as the completion of required docu-
mentation and training. Moreover, if unit hour utilization is measured simply on the basis
of the number of patient transports during a specified period, the resultant UHU will also
fail to capture the time spent responding to emergency calls that do not result in patient
transports. Finally, increased unit hour utilization can result in provider fatigue and medi-
cal errors, especially in EMS systems that have 24-hour shifts.

Shift schedules. Personnel costs account for the majority of an EMS system’s budget.
Accordingly, the staffing model employed by a system is a key factor. Several different
models have been adopted by EMS agencies across the country, each reflecting the unique
needs and priorities of particular EMS systems. However, four staffing models predominate.
Twenty-four-hour shifts are most prevalent in fire-based EMS systems. The 24-hour
shift model allows for the easiest integration between fire and EMS shifts and is best-
suited for low-volume systems that prioritize reliable response times.11
The 12-hour shift is most frequently the choice of private or third-service EMS sys-
tems, particularly those that serve large cities. This model allows for increased pro-
ductivity (in order to meet the demands of high-volume systems) while taking into
consideration the provider fatigue that is associated with longer work hours.12,13
Lastly, 8-hour and 10-hour shift staffing models have been adopted by several high-
volume EMS systems. These models allow for the highest level of productivity during
each shift in addition to providing the greatest flexibility for dynamic and peak-time
deployment of EMS units.14 However, they require more staffed positions than the other
models and have been associated with higher employee turnover and possibly increased
overtime costs due to the greater number of shift changes each day.

Health care reform

Triple Aim. Over the last decade, economists and policymakers have largely abandoned
the belief that better health outcomes could only be achieved through increased
spending. Instead, many changes to the health care system, including some of those
created by the Affordable Care Act, are now based on the “Triple Aim,” which states that
it is possible to simultaneously improve the patient experience, reduce health care costs,
and improve the population’s health.15

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The New EMS Imperative: Demonstrating Value

Proponents of the Triple Aim argue that by reducing inefficiencies, coordinating ser-
vices, and providing evidence-based, patient-centered care, costs can be reduced by elimi-
nating redundancies and avoiding unnecessary tests, procedures, and other health care
spending. This model also shifts the focus of health care to prevention and education,
with the belief that spending money to prevent injury, illness, and chronic disease will
decrease the high costs associated with treating those problems once they occur.

Fee for quality vs. fee for service and value-based payments. Concerns over the fee-
for-service model and its incentives have given rise to value-based reimbursements and
the fee-for-quality model. While these changes have yet to impact EMS directly, hospitals
and other health care providers are already seeing changes to how they are reimbursed
by the Centers for Medicare & Medicaid Services, and many EMS leaders across the
country have predicted that within a few years, these changes will directly impact EMS
payments as well.16

Affordable Care Act

The Affordable Care Act, in addition to its efforts to expand insurance coverage, also included
some changes to the Centers for Medicare & Medicaid Services reimbursement system that
follow the Triple Aim model. In general, the goal is to incentivize hospitals and physicians
to keep patients healthier by no longer rewarding providers for ordering more tests and
procedures and keeping patients in the hospital longer. The Affordable Care Act does not
discuss emergency care or EMS at length. However, the law still presents challenges and
opportunities for the emergency health care system, including emergency medical services.

Medicare reimbursement
While Medicare patients only make up a small percentage of the population, they
comprise a large percentage of those who are hospitalized and make up a significant
chunk of total spending on health care in the United States. So when the federal
government changes Medicare reimbursement policies, the effect is typically seen across
the entire health care system.
As part of the Affordable Care Act, Medicare has changed how it reimburses hospitals.
One of the most significant changes is that hospitals now receive penalties for high rates
of readmission for certain conditions. In the past, when a pneumonia patient who was sent
home from the hospital returned two weeks later, the hospital could bill twice for the patient.
Now, in an effort to encourage hospitals to ensure the patient is able to remain healthy once
they leave the building, that return visit will result in a penalty. The hope is that hospitals
will now spend more time making sure that patients are prepared to go home, by providing
adequate discharge instructions and ensuring proper follow-up care (such as doctor’s visits,
prescription medications, rehab, and home health).

Accountable Care Organizations

The ACA also promoted the formation of Accountable Care Organizations. ACOs are
networks of providers, such as doctors and hospitals, that work together to treat a specific
group of Medicare patients, similar to HMOs. However, unlike HMOs, patients are not
restricted to seeing only providers within the network. Also, ACOs are held accountable
to certain benchmarks and quality measures. The goal is that rather than saving money
by denying care that will help a patient, ACOs will save money by coordinating care to
keep patients healthier and avoid duplication of efforts. Under the ACA, an ACO that
demonstrates a certain amount of savings is then eligible to retain some of the savings
among the providers and hospitals.

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The New EMS Imperative: Demonstrating Value

In the past, health care worked like a restaurant menu: The more you ordered, the
more you (or your insurer) paid. Unlike a restaurant, however, consumers often didn’t
know whether the services were any good, rarely knew the costs, and sometimes didn’t
know if they had other options. So if they were treated but got sick again a few days
later, their physician or the hospital would treat them a second time and charge for the
second visit—in some ways, making more money because their initial efforts were unsuc-
cessful, whether that was preventable or not.
In the fee-for-quality model, the goal is to reward providers and hospitals who keep
patients healthy and treat problems efficiently and effectively. There are many different
combinations of these two models, and the current health care system still relies heavily
on fee-for-service. However, accountable care organizations are an example of the grow-
ing move toward fee for quality, as are Medicare reimbursement penalties (see “Afford-
able Care Act” sidebar).
In the long run, the hope is that fee-for-quality will produce more savings, as provid-
ers try to avoid hospitalizations, ER visits, and severe illnesses, because of their high
costs, by focusing on prevention and earlier, less costly interventions. While how these
changes will impact EMS remains unclear, what is obvious is that EMS agencies that
want to provide high-quality care and want to be reimbursed for that care will have to
demonstrate value and prove they enhance the patient experience and improve the popu-
lation’s health.

Solutions
Becoming more cost-effective

Strategic prioritization and deployment. The reality of limited funding and competing
priorities requires that local governments think strategically about how best to deploy
resources and personnel. This is especially true when it comes to the fire department,
whose primary mission has been overtaken by the growing demand for emergency
medical services. EMS calls now account for almost 70 percent of all calls for fire
department service, while less than 5 percent are due to actual fires.17 As a result, the fire
service has increasingly sought to emphasize its role in EMS delivery, in order to both
justify continued funding and ensure its future relevance.
Fire departments are arguably well-positioned to deliver emergency medical services.
The distribution of fire stations across most communities allows for relatively quick
response times. Many fire departments also provide an “all-hazards” capability (including
expertise in rescue, extrication, and hazardous materials) that complements the needs of
an EMS system. Most importantly, the decline in the number of fires (relative to the pop-
ulation) over the past 30 years has resulted in excess capacity within the fire department
that can be re-tasked to provide EMS.18
However, the use of fire apparatus to transport dual-role firefighters to the scene of a
medical emergency is not very cost-effective in terms of maintenance and fuel costs. Nei-
ther is upgrading fire apparatus to be advanced-life-support capable, which also requires
the addition of ALS personnel and equipment. Consequently, fire-based EMS systems
have begun to explore new deployment models.
Two other deployment options that may increase cost-effectiveness include:
• Adjusting the number of ambulances placed in service during specific time periods to
match anticipated changes in the level of demand during a 24-hour period
• Changing the geographic deployment of ambulances over the course of a shift to
match anticipated changes in the location of calls for service.

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The New EMS Imperative: Demonstrating Value

Advanced life support versus basic life support

In recent years, discussions regarding the cost-effectiveness of an EMS system have
increasingly focused on its ability to deliver advanced life support (ALS) care to the
community. ALS providers (paramedics and certain intermediate-level providers) are trained
to provide advanced emergency care including high-level assessment, complex invasive
skills, and a wide range of pharmacological interventions. By contrast, basic life support
(BLS) providers (emergency medical technicians and first responders) are trained to provide
preliminary management of emergent patients including basic assessment, non-invasive
skills, and a limited set of pharmacological interventions.
Over the past decade, many communities have sought to expand their ALS service, usu-
ally by increasing the number of ALS-capable units in the EMS system. In fire-based EMS
systems, this has been accomplished by “upgrading” fire apparatus (which formerly served
a BLS first-response role) and staffing them with ALS personnel and equipment.
The primary justification for this shift toward ALS first-response has been to reduce the
time it takes for an ALS-capable unit to respond to the scene of a call. However, less than
half of all EMS calls actually require ALS care and many of the time-critical interventions
that were once the domain of ALS providers can now be performed by BLS providers.19
These now-BLS interventions include defibrillation for cardiac arrest, which was the origi-
nal impetus for measuring ALS response times but is now routinely delivered by BLS pro-
viders and even untrained bystanders.
None of this is to say that ALS providers are not an important part of an EMS system.
Certain conditions benefit greatly from ALS care, such as calls for breathing problems.20
Also, as EMS systems evolve beyond simply providing treatment and transport to the hos-
pital emergency department, the ability of ALS providers to provide advanced assessment
and clinical judgment may increase their value on non-critical calls as well.
Increasing the number of ALS providers in an EMS system, however, may actually result
in worse quality of care—by reducing each individual provider’s exposure to truly critical
patients and limiting opportunities to maintain proficiency through the regular perfor-
mance of advanced interventions.21
A cost-effective EMS system will have a mix of ALS and BLS resources and reserve lim-
ited (and expensive) ALS resources for those patients who stand to benefit most from ALS
care. Other factors such as dispatch center capabilities, area geography, call acuity, train-
ing resources, community expectations, and political and financial constraints must also be
considered when determining the best allocation of ALS and BLS resources in each EMS
system.

Performance measures. One of the first steps toward ensuring cost-effectiveness in any
EMS system is to measure its performance. Unfortunately, EMS has historically suffered
from a lack of generally-accepted clinical performance measures.22 This has made it
difficult for EMS systems to evaluate and benchmark the quality of care that they deliver.
In 2007, a group of EMS physicians proposed a set of clinical performance bench-
marks.23 They focused on specific interventions (such as the administration of aspirin for
heart attacks) that have been shown to improve patient outcomes for certain conditions.
Since then, other organizations have published broader performance measures for EMS
systems.24,25 The National Association of State EMS Officials (NASEMSO), in partnership
with National Highway Traffic Safety Administration (NHTSA), has recently launched an
effort to create a new set of evidence-based EMS performance measures that will be com-
pleted in 2016.
Use of performance measures in emergency medical services can be problematic,
however. Efficiency and output goals, such as response times and unit hour utilization,

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The New EMS Imperative: Demonstrating Value

can fail to provide an accurate representation of EMS system performance. In addition,

very few outcome goals exist (“survival to hospital discharge” after a cardiac arrest being
one example). Nevertheless, performance measures can still provide valuable informa-
tion regarding an EMS system’s success in meeting established objectives and goals and
inform decisions regarding staffing levels and deployment models.

Data analysis. In order to make the most effective use of performance measures,
many EMS systems now use commercial data-analysis systems to capture and analyze
information on system performance. These systems can access data from several sources
including dispatch software, electronic patient care reports, and hospital databases, and
then display key performance indicators on data “dashboards”—often in real-time.
As EMS systems evolve, data analysis based on operational and clinical performance
measures will become critical. Hospital systems and physicians have already seen reim-
bursement tied to performance, and many EMS experts suggest a similar model will be
applied to EMS payments in the near future. Additionally, for reasons ranging from poten-
tial liability to patient and community satisfaction to, ultimately, the quality of patient
care, agencies need to have a robust continuous quality improvement (CQI) program that
relies on data analysis, sentinel case reviews, and education.
One crucial aspect of any CQI program will be bi-directional sharing of information
between EMS agencies and the hospitals (or other health care providers) with which
they interact. For example, in Sedgwick County, Kansas, the EMS system has access to a
dashboard that pulls information from both the EMS dispatch and patient care reports as
well as the hospital medical records, so EMS agency leaders can correlate treatments and
assessments performed by prehospital personnel with the ultimate diagnosis and disposi-
tion of the patient after delivery to an emergency department.26

Evidence-based guidelines. Another way that EMS systems can ensure cost-effectiveness
is to focus on delivering clinical interventions that have been proven to work. The field
of emergency medical services, however, has long-suffered from a lack of evidence-
based guidelines. Instead, much of EMS practice has been based on limited (and often
anecdotal) evidence and an overreliance on expert opinion.27
In response to this problem, the federal government has developed a model process
for the creation of nationally accepted evidence-based guidelines for emergency medical
services.28 This model has now been applied to develop evidence-based guidelines for
several conditions including pediatric seizures, pain management, and severe bleeding.
In addition, the National Association of State EMS Officials has recently released national
“model” EMS guidelines, which include both evidence-based and consensus-based clini-
cal guidelines.29
EMS systems are free to adopt or ignore these new guidelines as they see fit. At the
very least, however, EMS systems should review the guidelines in order to inform their
own protocols. Interventions that are supported by clinical evidence should be prioritized
over those that are not, while still keeping in mind the specific needs and resources of a
particular community.

Medical oversight. An EMS system is unlikely to be very effective in the absence of

strong medical oversight. Securing the services of a qualified medical director—one who
is actively engaged in the EMS system—can be difficult, however. In some communities,
physicians who are willing to take on the role of EMS medical director may be in short
supply. In others, cost may be a significant obstacle.
Thankfully, an increasing number of emergency physicians interested in the role of
medical director are completing fellowship programs in EMS. In 2010, EMS was accepted

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The New EMS Imperative: Demonstrating Value

as a board-certified subspecialty for physicians with experience or training in EMS medi-

cal direction. The first certifications were bestowed in 2014.
If cost is a factor, a local government may seek to contract for specific medical direc-
tion services. The National Association of EMS Physicians has adopted a set of recom-
mended qualifications and responsibilities for EMS medical directors, and these may be
narrowed down and prioritized as necessary to meet budgetary constraints.30

Regionalization. Adopting a regional approach has the potential to significantly improve

the cost-effectiveness of EMS systems. Currently, a high level of fragmentation exists,
which often results in poor coordination between EMS agencies.31 This problem of
fragmentation is often compounded by incompatible communications systems and
inter-agency rivalries. The end result is that neighboring systems may duplicate service,
especially in large urban centers, or fail to provide effective service in rural areas.
Local governments should increase the regionalization of EMS delivery wherever pos-
sible. Mutual-aid agreements can effectively address both duplication and service short-
falls. Co-locating or consolidating dispatch centers can improve coordination and also
generate significant efficiencies. Finally, establishing a regional EMS entity can provide
a foundation for increased collaboration between neighboring EMS agencies (includ-
ing with respect to funding and resource deployment) and possibly even their eventual
consolidation.

Call-taking, dispatch, and triage. The performance of an EMS system is closely tied
to the performance of its 911 call center, also known as a public safety answering point
(PSAP). Delays in answering, processing, and dispatching EMS calls at a PSAP result in
downstream delays in response times, scene times, and transport times—and possibly
contribute to worse patient outcomes. Improving the performance of the community
PSAPs is another way to increase the cost-effectiveness of EMS systems.
Technological advancements over the past two decades have revolutionized 911 call-
taking and dispatch. Most PSAPs now use enhanced 911 (E911) systems, which automati-
cally identify the telephone number and address of 911 callers.32 In the past several years,
E911 systems have been upgraded to include wireless phones in addition to landlines.
Efforts are currently underway to expand the E911 system capabilities to also include call-
ers using voice-over-IP services such as Skype and text messaging. Other advanced tech-
nologies, such as computer-aided dispatch and automatic vehicle location, have further
enhanced the capabilities of PSAPs.
However, it is estimated that almost a quarter of 911 calls are for medical care that
does not require emergent transport to the hospital.33 These calls unnecessarily occupy
911 call takers and emergency dispatchers, and have the potential to delay the dispatch of
EMS units to true medical emergencies.
Public education efforts have done little to stem the growing tide of 911 calls for non-
emergent medical conditions.34 Some communities are now piloting programs that will
allow PSAPs to more effectively manage the increasing volume of calls for both emer-
gency and nonemergency medical services. One example is the use of nurses at a PSAP
to provide advanced medical triage.
Employing nurses to triage nonemergency medical calls can free up call takers and
dispatchers to focus on calls for emergency service. PSAP nurses can refer nonemergency
callers to more appropriate health care resources (e.g., an urgent care center or clinic)
and also improve EMS system efficiency by allowing dispatchers to prioritize calls for ser-
vice based on medical urgency and potentially even schedule an ambulance to respond
during periods of lower demand.

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The New EMS Imperative: Demonstrating Value

Taking advantage of opportunities: Mobile integrated health care and community

paramedicine
The concept of community paramedics—EMS providers who provide a broader array of
services and focus on prevention and primary care—is not a new one, but it has gained
renewed focus in recent years, thanks in large part to the advent of the Triple Aim phi-
losophy and the ACA.35
Community paramedicine means different things to different people within the EMS
community. In more rural locations, community paramedicine initially developed as a
way to provide basic primary care services in areas with limited medical resources and to
avoid long, expensive trips to distant hospitals for minor problems. In this setting, com-
munity paramedics often had a scope of practice beyond that of most other paramedics,
which might include wound care, suturing, and even antibiotic administration.
Urban and suburban communities, realizing that it is in the best interest of both
patients and community health to prevent illnesses and hospitalizations whenever possi-
ble, have begun to experiment with a new type of community paramedicine, which some
are now calling “mobile integrated health care.”
Mobile integrated health care (MIH) is broader than community paramedicine in that
it contemplates using providers and organizations of all types to provide the best care in
the home and other nonclinical environments.36 Accordingly, most community paramedi-
cine programs can fall under the umbrella of mobile integrated health care, but not all
MIH programs necessarily use the community paramedic model.
MIH programs often employ EMS providers who receive advanced training on topics
such as chronic disease management and mental health issues, but whose technical and
medical scope of practice remains unchanged.
The passage of the Affordable Care Act has contributed to a significant increase in
the number of EMS agencies providing MIH services across the country. Some have been
subsidized by EMS agencies and fire departments that hope to decrease the demand on
emergency services. Others have attempted to capitalize on changes to the Medicare
reimbursement model and have partnered with hospitals to reduce readmissions, hoping
hospitals will want to pay for the service in order to avoid Medicare penalties.
Among some EMS leaders, there is a concern that EMS agencies are diving headfirst
into MIH without a clear path to sustainability. At the same time, however, there is also
growing agreement that the current EMS response and funding model is not sustainable.
Local government should therefore assess the available resources and the financial, politi-
cal, and regulatory climate before deciding which type of MIH program, if any, is appro-
priate in their particular communities. In any case, MIH programs will not eliminate the
need for emergency response or the use of EMS as a safety net by some members of the
community.

Typology of MIH programs. Much like EMS systems, almost no two MIH programs look
exactly alike (Table 2 includes examples of MIH programs from across the United States).
However, there are several categories of services that generally encompass the bulk of
MIH activities:
Physician extender. These programs place EMTs, paramedics, or mid-level practitioners
(e.g., nurse practitoners, physician assistants) in the community to provide medical ser-
vices that do not require hospitalization. This could include treating minor injuries with
suturing or evaluating minor illnesses and providing medications.
Adjunctive mobile care. Programs that are created to fill gaps in the community—often
to avoid unnecessary hospital visits—include re-admission avoidance, hospice revocation
avoidance, and post-discharge care. Typically, these programs involve a home visit by the
EMS provider, who reviews discharge instructions, does an in-home assessment, recon-

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The New EMS Imperative: Demonstrating Value

ciles medication lists, and ensures patients are following up with a primary care provider
or appropriate specialist.
Patient triage and navigation. Traditionally, EMS systems have provided patients
with two options—either a transport to the emergency room, or nothing. Several agen-
cies are now exploring other options, both to improve the patient experience and to
decrease the burden on emergency medical resources. These programs include connect-
ing 911 call centers to nurse help lines for low-acuity illnesses and injuries; allowing EMS
responders to treat and release patients on scene or transport them to facilities other than
hospitals, such as behavioral health facilities, urgent care clinics, or detox centers; and
addressing frequent EMS users through education, linkage to other resources, and other
interventions.
Occupational and community health services. These programs may include education
and outreach efforts, such as fall prevention education for elderly members of the com-
munity; on-site injury assessment at workplaces to avoid unnecessary trips to the emer-
gency department and associated costs; and immunizations.

Table 2: Examples of community paramedicine/mobile integrated health care

practice programs
MedStar (Fort Worth, Texas)
www.medstar911.org
In 2013, MedStar EMS, the sole provider of nonemergency and emergency ambulance
services in Fort Worth and 14 other surrounding cities, changed its name to MedStar Mobile
Healthcare. The new moniker reflects a realization in the EMS community that even many
911 calls do not result in “emergency care” so much as “unscheduled health care.”
MedStar has been one of the most aggressive innovators in the realm of mobile integrated
health. As a public utility system, MedStar has a government-mandated monopoly on ser-
vices but also the flexibility to adapt. MedStar has launched several community health pro-
grams in recent years, many of which highlight the importance of partnerships to ensuring
positive patient outcomes and fiscal sustainability.
SSpecially trained mobile health paramedics, who use vehicles that are not equipped to
respond to emergencies, perform in-home visits with frequent 911 callers, recently discharged
Medicare patients, and others who may be at risk of becoming an EMS or emergency depart-
ment patient in the future. The agency has also partnered with local hospice and home health
agencies as well as insurers and hospitals. These partners pay MedStar to provide these mobile
health services in order to prevent patients from having further hospitalizations.

Mesa Fire and Medical (Mesa, Arizona)

www.mesaaz.gov/fire
Like MedStar, the Mesa Fire Department recently acknowledged the shifting priorities
of the fire service by changing its name to the Mesa Fire and Medical Department. The
department also received a $12.5 million Center for Medicare and Medicaid Innovation
(CMMI) grant to expand its Community Care Units program, which partners paramedics
with other health care providers to provide appropriate care to patients and free-up other
resources to respond to emergency calls.
The department’s Community Care Units look like ambulances, but each varies in how it
is staffed. One unit partners a paramedic with a nurse practitioner or physician assistant,
who is employed by Mountain Vista Medical Center. That mid-level practitioner can often
handle low-acuity emergencies by prescribing a medication, treating someone’s pain, or
(continued)

12 ©2015 ICMA
The New EMS Imperative: Demonstrating Value

Table 2: Examples of CP/MIHP programs (continued)

even suturing a wound in the field, preventing an unnecessary ambulance ride and emer-
gency department visit.
A second unit partners a paramedic with a crisis counselor to respond to behavioral emer-
gencies and determine if the patient might be better served at a psychiatric facility rather
than the emergency room. Partnering with these other health care providers has allowed the
department to expand the scope of services it can provide in the field.

REMSA (Reno, Nevada)

www.remsa-cf.com
Before Mesa received its federal grant, REMSA was the recipient of the largest CMMI award
to an EMS agency. REMSA, a public utility EMS agency in Reno and surrounding Washoe
County, Nevada, launched a nurse health line, a community paramedic program, and an
alternative destination program, all funded by the CMMI grant.
REMSA felt its patients often had a simple question or problem but turned to 911 because
they did not know who else to call. And public safety dispatch centers were designed to han-
dle emergencies, so the response was always the same: dispatch EMS. REMSA established
a nurse health line for people to call, regardless of their insurance status or provider. The
nurses were trained to provide advice over the phone and to recognize serious emergencies.
Unlike other nurse hotlines, REMSA’s is directly tied to the EMS dispatch center, so calls can
be seamlessly referred between the two. Calls coming into 911 for very low-acuity issues are
transferred to a nurse, often eliminating the need for EMS response.
The alternative destination program allows REMSA’s EMS providers to take patients to
destinations other than emergency departments, such as urgent care clinics. Many of the
patients have minor illnesses and injuries that can be handled by these clinics, decreasing
the cost of care and relieving stress on the emergency system.

Wake County EMS (Raleigh, North Carolina)

www.wakegov.com/ems
In Wake County, North Carolina, the public “third service” agency that provides 911 EMS
response and transport added a new level of provider: the advanced practice paramedic
(APP). These APPs receive additional training and supplement the emergency response
system, ensuring the presence of an additional, experienced paramedic on critical
incidents. But the main success of the program has been when the APPs conduct in-home
visits with frequent callers and patients who are referred by other EMS providers who feel
the patient needs additional services.
In addition, Wake’s advanced practice paramedics are able to medically clear intoxi-
cated patients so they can be taken directly to a detox facility, preventing the utilization
of an ambulance and hospital bed for a person without a medical need for either. Simi-
larly, they can evaluate psychiatric patients in the field in order to determine the most
appropriate destination and get those patients the services they need in a more timely
and cost-effective manner.

Other Considerations
Workforce
The EMS workforce is a critical component of any EMS system, and also a large part of
the overall cost of any EMS system. Because EMS delivery models can vary greatly, how-
ever, EMS workforces also often differ in terms of required qualifications, promotional
opportunities, and labor representation.

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The New EMS Imperative: Demonstrating Value

Fire-based EMS systems typically have the highest personnel costs, due to higher
salaries, generous pensions, and 24-hour shift schedules for dual-role firefighters. EMS
systems that employ single-role EMTs and paramedics often pay smaller salaries but also
generally experience high turnover rates.
Organized labor is more prominent in fire-based systems, as the International Associa-
tion of Fire Fighters (IAFF) has become one of the nation’s largest and most politically
active unions. Civilian EMS providers who are unionized are represented by a wide range
of different labor groups across the country.
Maintaining a dialogue with the workforce—whether organized or not—is critical for
local governments seeking to make changes to their EMS systems. Strong opposition from
labor can sink proposed changes before they are even proposed. This is especially true
for changes to pay levels or shift schedules, as was evident when the (now former) fire
chief in Washington, D.C., proposed switching from 24-hour shifts to shorter work peri-
ods as a potential cost-saving measure.37

Community needs assessment

Whether considering a new mobile integrated health program or simply trying to improve
upon existing EMS services, it is critical that municipalities and EMS agencies evaluate
and assess the community’s needs first.38 Programs that are created simply to increase
revenue or copy another community’s model may not be appropriate and are likely to
struggle or fail. The process of conducting a needs assessment will vary depending on
the size of the community, the available resources, and the types of changes being con-
sidered, but every needs assessment should include dialogue with community stakehold-
ers in order to determine what service gaps exist.
Without assessing community needs, it is quite likely that a community will estab-
lish a program that is redundant or unnecessary. As noted earlier, several EMS agencies
across the country have established programs to address frequent users of 911 services.
In San Diego, an analysis of those users determined that many of them had alcohol or
substance abuse problems in addition to being chronically ill and sometimes homeless.
In McKinney, Texas, however, the local EMS agency found that most of its frequent call-
ers were elderly and had chronic conditions, but very few had substance abuse problems
and almost none were homeless.39 The resources needed to address the problems in these
two cities are vastly different, and only through assessing the problem and the existing
resources were the two cities able to establish programs.

Regulatory environment
As EMS agencies look for ways to improve service and adapt to a new health care envi-
ronment, states have struggled to keep pace with the changes happening at the local
level. Because many state EMS regulations limit paramedics’ and EMTs’ scopes of prac-
tice to “emergency situations,” some programs aimed at prevention and patient naviga-
tion have stalled. States with a less stringent EMS regulatory structure, such as Texas,
have seen a rapid growth in these programs; other states have taken a slower approach,
as in California, where EMS regulators plan to dip their toes in the water with a handful
of state-approved pilot programs.40
In Minnesota, a lobbying effort led to legislative recognition of community paramedics
and the services they provide in 2011. Minnesota remains the only state where commu-
nity paramedic services are specifically recognized and reimbursed by the state’s Medic-
aid system. Most states still lack a regulatory definition of a community paramedic or an
advanced practice paramedic, and prehospital providers filling these roles are certified at
the EMT or paramedic level with no state-recognized expanded scope of practice.41

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The New EMS Imperative: Demonstrating Value

While responsibility for regulation of EMS lies with the states, federal agencies have
shown support of innovative EMS programs. The Center for Medicare and Medicaid Inno-
vation (CMMI), created by the Affordable Care Act, has awarded several multi-million-
dollar grants to support EMS agencies’ community health programs. The three agencies
most involved in EMS issues also published a draft white paper entitled “Innovation
Opportunities for Emergency Medical Services,” in which they suggest that EMS could
play a major role in improving the effectiveness and efficiency of the health care system
by considering alternatives to the traditional model of transporting every patient to the
emergency department.42

Potential partners

Payers. Private payers for health care services have an obvious incentive to partner
with EMS systems that are able to provide cost-effective health care services under the
umbrella of community paramedicine. EMS systems that offer preventive health services,
mobile care (such as home visits to patients with chronic conditions), and patient
navigation (such as transport to a local clinic) may also find that insurance companies
are willing to subsidize their services.

Hospitals. Hospitals have a particular incentive to partner with EMS systems that
offer services aimed at reducing hospital readmissions. Since October 2012, the federal
government has imposed financial penalties on hospitals with “excessive” readmissions
for certain conditions.43 In order to avoid such penalties, hospitals may be willing to pay
EMS systems to provide post-discharge follow-up to their patients.

Home health care and hospice agencies. Home health care and hospice agencies may also
have incentives to partner with EMS systems, but only if community paramedicine programs
seek to complement rather than compete with their own services. For example, home health
care and hospice agencies may be willing to compensate EMS systems for triaging and
providing care to their patients who call outside of their normal operating hours.

Funding models

Public and private subsidy. Community paramedicine programs are unlikely to be

entirely self-sustaining. Their true worth, however, should be judged in terms of their
impact on the cost-effectiveness of the overall EMS system. If such programs are able to
help EMS systems more efficiently manage the ever-increasing demand for emergency
medical services, then a certain level of local government funding may be appropriate.
This is also true for community paramedicine programs that are successful in addressing
currently unmet community health care needs.
It is likely that public health care payers at the state and federal levels (e.g., Medicare
and Medicaid) may eventually offer some level of public subsidy for community para-
medicine services. Thus far, however, they have focused their efforts on grant funding for
pilot projects.
Private health care payers, hospitals, and certain private health care providers may also
directly subsidize certain community paramedicine services provided by EMS agencies.

Fee for service. It will be difficult for community paramedicine programs to seek direct
reimbursement from health care payers on a fee-for-service basis. Existing billing codes
simply do not contemplate the provision of health care services by EMS providers. Efforts
to expand their scope to include community paramedicine services have met with very
limited success.

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The New EMS Imperative: Demonstrating Value

Shared savings and capitated payment. The shared savings model offers the greatest
potential for private funding of community paramedicine services. EMS systems that are
able to demonstrate cost savings to private health care payers or hospital systems (e.g.,
reduced health care costs from patient navigation or reductions in financial penalties due
to readmission avoidance efforts) may be able to enter into an arrangement whereby they
share in those cost savings. The shared savings model is likely to become more appealing
as the health care system moves away from fee-for-service reimbursement toward
population-based payment models.

Conclusion
In health care and government, providing high-quality service and being cost-effective are
no longer thought to be mutually exclusive. Emergency medical services in the United
States are at a crucial juncture, as the public continues to demand prompt, effective
response; municipal budgets are strained; and ambulance reimbursements decrease. EMS
systems must prepare for a future when simply responding to every call with lights and
sirens and transporting every patient to the hospital emergency department is no longer
a sustainable model. While the path forward is still not entirely clear, systems that adopt
an evidence-based and patient-centered approach, consider innovative ways of providing
traditional 911 EMS service, and take advantage of new opportunities to provide appropri-
ate nonemergency services to their communities will be well-positioned to effectively—and
efficiently—respond to the changes coming to health care and EMS in the United States.

Endnotes
1 Institute of Medicine Committee on the Future of Emergency Care in the US Health System.
“Emergency medical services: at the crossroads.” Washington: DC (2006).
2 “Innovation Opportunities for Emergency Medical Services: A Draft White Paper from the
National Highway Traffic Safety Administration (DOT), Office of the Assistant Secretary for Pre-
paredness and Response (HHS), Health Resources and Services Administration (HHS),” July 15,
2013, accessed October 20, 2014, http://ems.gov/pdf/2013/EMS_Innovation_White_Paper-draft.pdf.
3 National EMS Advisory Council, “EMS system performance-based funding and reimbursement
model,” May 31, 2012, accessed October 20, 2014, http://www.ems.gov/nemsac/FinanceCommittee-
AdvisoryPerformance-BasedReimbursement-May2012.pdf.
4 Ibid.
5 Ibid.
6 National Fire Protection Agency Standard 1710, “Standards for the organization and deploy-
ment of fire suppression operations, emergency medical operations, and special operations to
the public by career fire departments” updated 2010.
7 Eisenberg, Mickey S., Lawrence Bergner, and Alfred Hallstrom. “Cardiac resuscitation in the
community: importance of rapid provision and implications for program planning.” JAMA 241, no.
18 (1979): 1905–1907.
8 Blackwell, Thomas H., “EMS Response Time Standards,” in Evidence-based System Design
White Paper for EMSA, eds. J.M. Goodloe and S.H. Thomas (2011), 18–29, accessed October 20,
2014, http://www.naemsp.org/MDC%20References%20for%20Website/OUDEM%20EMS%20
System%20Design%20White%20Paper%20FINAL%20for%20July%202011%20Release.pdf.
9 Bailey, E. David, and Thomas Sweeney. “Considerations in establishing emergency medical ser-
vices response time goals.” Prehospital Emergency Care 7, no. 3 (2003): 397–399.
10 Fitch and Associates, “How to Explain UHUs from UFOs to Your City Manager,” EMS1.
com, November 8, 2012, accessed October 20, 2014, http://www.ems1.com/ems-management/
articles/1365144-How-to-explain-UHU-from-UFOs-to-your-city-manager.

16 ©2015 ICMA
The New EMS Imperative: Demonstrating Value

11 Miramonti, Charles, “Scheduling Deployment Models,” in Goodloe and Thomas, Evidence-based

System Design, 40–53.
12 Ibid.
13 International Association of Fire Chiefs, “Effects of sleep deprivation on firefighters and
EMS responders,” June 2007, accessed October 20, 2014, http://www.iafc.org/files/progssleep_
sleepdeprivationreport.pdf.
14 Miramonti, Charles, “Scheduling Deployment Models.”
15 Berwick, Donald M., Thomas W. Nolan, and John Whittington. “The triple aim: care, health, and
cost.” Health Affairs 27, no. 3 (2008): 759–769.
16 Matt Zavadsky, “Get Ready for Value-Based Purchasing,” EMS World, June 2014, 16–17.
17 National Fire Protection Administration, “Fire Department Calls,” September 2014, accessed
October 20, 2014, http://www.nfpa.org/research/reports-and-statistics/the-fire-service/
fire-department-calls/fire-department-calls.
18 Fahy, Rita F., Paul R. LeBlanc, and Joseph L. Molis. “What’s changed over the past 30
years?.” National Fire Protection Association (2007): 1–15.
19 Eckstein, Mark K., “Basic and advanced life support considerations,” in Goodloe and Thomas,
Evidence-based System Design, 30–39.
20 Stiell, Ian G., Daniel W. Spaite, Brian Field, Lisa P. Nesbitt, Doug Munkley, Justin Maloney, Jon
Dreyer et al. “Advanced life support for out-of-hospital respiratory distress.” New England Journal
of Medicine 356, no. 21 (2007): 2156–2164.
21 Pouliot, Ryan C. “Failed prehospital tracheal intubation: a matter of skill dilution?.” Anesthesia
& Analgesia 110, no. 5 (2010): 1507–1508.
22 Myers, J. Brent, Corey M. Slovis, Marc Eckstein, Jeffrey M. Goodloe, S. Marshal Isaacs, James
R. Loflin, C. Crawford Mechem, Neal J. Richmond, and Paul E. Pepe. “Evidence-Based Perfor-
mance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Bench-
marking: A Statement Developed by the 2007 Consortium US Metropolitan Municipalities’ EMS
Medical Directors.” Prehospital Emergency Care 12, no. 2 (2008): 141–151.
23 Ibid.
24 National Highway Traffic Safety Administration, “Emergency medical services performance
measures: Recommended attributes and indicators for system and service performance,” December
2009, accessed October 20, 2014, http://www.ems.gov/pdf/811211.pdf.
25 International Association of Fire Fighters & International Association of Fire Chiefs, “EMS sys-
tem performance measurement: Operations manual,” accessed October 20, 2014, http://www.iaff.
org/tech/PDF/EMSSystemPerformanceMeasurement.pdf.
26 Todd Stout, “Enhancing the Healthcare Continuum: How I.T. Solutions Can Help EMS & Hospitals
Collaborate,” presentation at Pinnacle EMS Leadership Forum, July 21, 2014.
27 Lang, Eddy S., Daniel W. Spaite, Zoe J. Oliver, Catherine S. Gotschall, Robert A. Swor, Drew E.
Dawson, and Richard C. Hunt. “A National Model for Developing, Implementing, and Evaluating
Evidence?based Guidelines for Prehospital Care.” Academic Emergency Medicine 19, no. 2 (2012):
201–209.
28 Brown, Kathleen M., Charles G. Macias, Peter S. Dayan, Manish I. Shah, Tasmeen S. Weik,
Joseph L. Wright, and Eddy S. Lang. “The development of evidence-based prehospital guidelines
using a GRADE-based methodology.” Prehospital Emergency Care 18, no. Supplement 1 (2014):
3–14.
29 National Association of State EMS Officials, “National Model EMS Clinical Guidelines,” Septem-
ber 15, 2014, accessed October 20, 2014, https://www.nasemso.org/Projects/ModelEMSClinical-
Guidelines/documents/National-Model-EMS-Clinical-Guidelines-15Sept2014.pdf.
30 Alonso-Serra, Hector, Donald Blanton, and Robert E. O’Connor. “Physician medical direction in
EMS.” Prehospital Emergency Care 2, no. 2 (1998): 153–157.

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31 Institute of Medicine, “Emergency medical services: At the crossroads.”

32 National Emergency Number Association, “9-1-1 Statistics,” September 2014, accessed October
20, 2014 https://www.nena.org/?page=911Statistics.
33 Alpert, Abby, Kristy G. Morganti, Gregg S. Margolis, Jeffrey Wasserman, and Arthur L. Kellermann.
“Giving EMS flexibility in transporting low-acuity patients could generate substantial Medicare
savings.” Health Affairs 32, no. 12 (2013): 2142–2148.
34 Linda J. Johnson and Beth Musgrave, “Non-emergency ambulance runs burden, add to the
cost of Lexington’s EMS system,” Lexington Herald Leader, February 15, 2014, accessed January
11, 2015, http://www.kentucky.com/2014/02/15/3089002_911-frequent-flyers-non-emergency.html.
35 Krumperman, K. “History of community paramedicine.” EMS Insider 14651 (2010), http://www.
jems.com/article/ems-insider/history-community-paramedicine.
36 Mobile Integrated Healthcare Practice Collaborative, “Principles for Establishing a Mobile
Integrated Healthcare Practice,” Medtronic Philanthropy, 2014.
Training Planning
37 Alan Suderman, “Shorter Firefighter Shifts Still a Ways Off, Like Maybe Forever,” Washington
City Paper, October 31, 2012, accessed October 20, 2014, http://www.washingtoncitypaper.com/
blogs/looselips/2012/10/31/shorter-firefighters-shifts-still-a-ways-off-like-maybe-forever/.
38 Mobile Integrated Healthcare Practice Collaborative, “Principles.”
39 Michael Gerber, “How 4 Cities are Making Community Paramedicine Work for Them,” EMS1.
com, July 22, 2014, accessed October 20, 2014, http://www.ems1.com/community-paramedicine/
articles/1949030-How-4-cities-are-making-community-paramedicine-work-for-them/.
40 Alex Matthews, “The Paramedic Will See You Now,” California Health Report, August 28, 2013,
accessed October 20, 2014, http://www.healthycal.org/archives/13434.
41 “Beyond 911: State and Community Strategies for Expanding the Primary Care Role of First
Responders,” NCSL, accessed October 19, 2014, at http://www.ncsl.org/research/health/expanding-
the-primary-care-role-of-first-responder.aspx.
42 “Innovation Opportunities for Emergency Medical Services.”
43 Centers for Medicare & Medicaid Services, “Readmissions Reduction Program,” August 4, 2014,
accessed October 20, 2014, http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
AcuteInpatientPPS/Readmissions-Reduction-Program.html.

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Volume 47/Number 1, Item number E-44001

Recent Reports
No. 2, 2014 New Council Member Orientation: Developing a Positive Relationship (E-43825)
No. 1, 2014 Effective Crisis Communication (E-43824)
No. 6, 2014 Effective Budget Communication (E-43751)
No. 5, 2014 Developing a Mobile Device Strategy for BYOD to Avoid “Bringing Your Own
Disaster” (E-43750)
No. 4, 2013 Engaging your Citizens Using Social Media (E-43749)
No. 3, 2013 No.311/CRM Systems: Changing the Face of Local Government ­­Customer
­Service (E-43748)
No. 2, 2013 Leveraging the Power of Employee Engagement (E-43747)
No. 1, 2013 Town–Gown Emergency Management Collaboration: Finding the Right Mix
(E-43746)
No. 6, 2012 Using Performance Measurement for Effective Strategic Planning (E-43745)
No. 5, 2012 Flexibility in Local Government: Using Nontraditional Strategies for Financial
Stability (E-43744)

Publishing and Information Resources

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Author’s Contact Information

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Fitch & Associates
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Box 170
Platte City, MO 64079
816-431-2600
[email protected]

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