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Keeping Rural EMS Reliable and Sustainable, with James Small

Date: December 5, 2023
Duration: 45 minutes

James Small.An interview with James Small, Rural EMS Outreach Director for the Wisconsin Office of Rural Health. We discuss workforce and funding shortages in rural emergency medical services, and how those services can be maintained and expanded.

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Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. Today I'm speaking to James Small. He's the Rural EMS Outreach Director for the Wisconsin Office of Rural Health. Thank you for joining us today, James.

James Small: Well, thank you for inviting me on today.

Andrew Nelson: Yeah. To get started here, can you just tell us a little bit about the Wisconsin Rural EMS outreach program, as well as your own background?

James Small: Okay. So, our rural EMS outreach program started in July of 2022, so we're just under a year and a half into our program. Our goal is to improve the reliability and sustainability of the rural ambulance services in Wisconsin. So, the way that we're doing that, we're working kind of at a macro level with things of statewide importance. Things that are potentially influencing legislation or other regulation of the state system, things that we can do on that. And then the other part of our program is that we work with local communities, so working with the local municipal bodies, working with individual services on individual problems they have within their services, kind of like a free organizational development consultant for these communities to pull on to help navigate some of these issues that are causing them to not have adequate EMS response.

I've just completed 30 years in EMS. I started when I was still in high school with a small service in northeastern Wisconsin. I worked for a rural sheriff's office for about 10 and a half years, and then went on, became the police and fire chief for a municipality up in the northwestern part of the state before then coming down and becoming a police and fire chief for a community in the southern part of Wisconsin. And I just retired from chiefing about six months ago now.

Andrew Nelson: Last fall your office conducted a study to evaluate Wisconsin's EMS sustainability and reliability. Why did you think there was a need for a study like that?

James Small: When I started in my role launching the EMS outreach program, we started looking at data and trying to understand what was going on in the system, because anecdotally, you're hearing all these stories of, there's poor coverage and there's nobody to work, and there's calls not being responded to and so on. But really, when it came down to real data, the best answer we are getting is nobody knows; “How many ambulances are supposed to be currently staffed in Wisconsin today?” Nobody knows. There's no way to determine that. How widespread is this problem that we're hearing about? You're hearing about this decline in volunteerism and those kinds of things, but is it really that bad? Is it worse than what they're saying it is? Nobody knows. So it really formed out of this idea that we needed to get an idea of what's going on at the ground level. We looked at a year's worth of data. So, we asked services to go back 12 months and just answer questions relating to if they were staffed and if they were able to respond to calls, did calls go unanswered in their communities, did other services have to come in under mutual aid? Things like that. We ended up finding that 41% of the services reported that they were not staffed 24/7, 365, like they're required to. There is some other data in that that suggests that number might be closer to 50%, so almost half, because there was 49% were saying that they had their neighbor do mutual aid for them because they weren't staffed with a first-out ambulance.

The other thing we found is that the conventional wisdom said that this was a very far-up-north problem. The northern third of Wisconsin is extremely rural with large national forests and things like that. And the conventional wisdom was saying, “Yes, those up-north departments.” But what we found is that these problems exist in all seven regions of the state. The state is divided into seven healthcare regions. All seven regions have significant issues within them. And we were able to get data from about 60% of the services in the state, and all the regions were well-represented in that. So this issue is a statewide issue, and I think we know that. We know that this is a nationwide issue. There's nobody that's figured this thing out yet. But to be able to quantify that, I think, was extremely helpful. And to just be able to say, “You know what, this is everywhere.” And it even included paid departments, paid urban departments were reporting that they were having service outages. So it's not just rural; it's worse in rural, and it's worse among volunteer departments versus paid departments. But it's not limited to rural, and it's not limited to volunteers.

Andrew Nelson: One of the things that I thought was interesting when I was looking over your study was the different obligations that towns and cities have as opposed to villages in Wisconsin when it comes to supplying EMS.

James Small: So in Wisconsin, EMS is a function of local government. That's where it originates from. So you have the state, which is then divided into 72 counties, and then there's roughly 1,600 towns, villages, or cities. So town forms of government which tend to be rural — there's only a few examples of urbanized townships in Wisconsin; most of them are very rural, agricultural-based or tourism-based economies — they are required to provide ambulance service. The statute says that a town government shall provide it, where then in contrast, cities and villages may provide that service. So they're allowed to, but they don't have to. Now that being said, there's no examples that we're aware of a city or village deciding not to have ambulance service or try to obtain it in some way. But it's just one of the mismatches that come up in the legislature over the years where a town government has to, but these cities and villages don't, which you would almost think it would be the opposite of that.

Andrew Nelson: It can be kind of interesting, some of these apparent inconsistencies that just sort of go unnoticed till somebody makes an effort to kind of get a sense of how all these things are fitting together. Another thing I was reading about is mutual aid; the way in which rural communities that are adjacent to each other can help each other out if there's insufficient personnel to respond to an incident. Can you tell me in a little greater depth about how that works and what its limitations are, and whether you think the amount of mutual aid that you currently have in rural Wisconsin is sustainable?

James Small: So the way mutual aid is designed to work is that you've exceeded your capacity with the amount of calls you may have going on. So, for example, your rural community staffs one ambulance, they're on another call, and then there's a second call for service. And then you would call the neighboring service to come in and assist you with that second call for service while you're on your primary call. What's happening is that Service A isn't staffed. They don't have a crew available. So when a dispatch isn't able to give a call to that crew, they then will go to the neighboring community to take that first call for service. And we know about four out of five services last year took a call under those circumstances.

Now, where that becomes a problem is when that's happening frequently. You're creating these cascading effects in regions. And outside of that study, we have dispatch data from some regions that really suggest that this can be very problematic. So imagine that Service A doesn't have a crew. So they get a call and it's given to Service B, but they don't have a crew either. So then the dispatcher goes to Service C, but what if they don't have a crew either? And Service D then gets called, they don't have a crew, and it keeps cascading through this system until an ambulance comes from 50 miles away, comes and takes the call, transports the person a few miles to the local Critical Access Hospital, then returns to their jurisdiction.

But what you've identified there through that dispatch data is that you have this huge desert, and I think most of us have seen the ambulance desert study that was done by the Maine office; a few months ago it was released. But that's talking about just what exists based on our infrastructure being staffed, where really what you're having is these intermittent deserts that might be covering hundreds of square miles at a time, but nobody knows it because everybody's counting on these ambulances that are placed strategically being staffed when they're not. And I think that's the bigger issue because this local taxpayer thinks that they have a 10- or 15- minute ambulance response coming, but that call might take them an hour and a half to get an ambulance, too. That's not counting the instances that we found in our study of 10 different communities that had calls happen where an ambulance never got to a call, ever. They could never get an ambulance. It's been suggested to me that that number is two to three times what we've identified. We can put a stake in the ground pretty hard that we know it's at least 10. And that covered an excess of 30 calls. So that's 30 times that somebody was in a very vulnerable place, either sick or injured, that someone called 911 to help them and nobody came.

Andrew Nelson: That's certainly very concerning. Rural communities often have more limited resources than urban areas, and volunteers have traditionally been the backbone of rural EMS. How is that working out for rural Wisconsin communities in particular, and what do you see as the way forward with staffing?

James Small: Well, I think we've seen a decline in volunteerism in society in general, probably going back 50 years or more at this point. In most cases, the volunteers aren't able to sustain that 24/ 7, 365 response coverage. As communities, we need to look at what level of service we expect. This is a governmental service being provided by local government. This isn't a situation where if the snowplow comes an hour later, it's not really that big of a deal, right? If the ambulance comes an hour later, it might be a big deal. So we need to decide what our expectation is for this, and is that volunteer model meeting that expectation? And I think what we're finding is that in a lot of communities, that's not the case anymore.

And it's not the fault of the volunteers, because I've seen that happen a lot working with local governments. The first thing that comes up is blaming the volunteer. Well, this person is providing this service for free, or nearly free, to directly lower the taxes for the people in that community. They're personally subsidizing the cost of that service. So to go back and say that it's somebody's fault that they're not volunteering enough or things like that, I think, is a fallacy because my experience with the volunteers, and having been a volunteer at one point in my life, these people are extremely dedicated. And the reason the system hasn't collapsed completely at this point is because of these volunteers and that dedication and that perseverance that they have. There's many, many examples of people doing 3,000, 4,000, 5,000 hours a year of call to make sure that the wheels keep turning on these ambulances.

But that's not sustainable, because is there somebody coming behind them to pick up that 5,000 hours a year when they can't do it anymore? So you're seeing things happen in these services where the numbers dwindle because people are aging out and they're not being replaced by young people. And in some of the rural communities, there aren't young people to replace them with. A lot of rural areas in Wisconsin have become retirement communities. You know, just since the pandemic, we've seen this huge surge in population into the northern areas where people had cabins, where they might be on the weekends in the summer, and now they're living there year-round. Well, that's put a bigger burden on the local services and the volunteers there too. But this person probably isn't going to go into EMS when they're 75 years old, right? So how are you getting the people to come in and create that workforce and still have other jobs and have the ability to do that? And I think it's very challenging creating the workforce, especially through that volunteer model.

Andrew Nelson: I suppose one of the biggest factors limiting volunteer participation is the fact that volunteers need to have a full-time job they're working in order to support themselves. Can you talk about some of the other funding challenges that face rural EMS?

James Small: Well, historically there just isn't the tax base in the rural communities to support that. Particularly with town forms of government in Wisconsin, they were receiving a lower amount of shared revenue from the state. That's a part of the state's contribution to each of the local municipalities from the state's taxation to provide local services. But really, if you look at how EMS was done in Wisconsin, going back into the '60s and early '70s, there really wasn't a lot of funding put into this system in the first place. You know, the amount of shared revenue that municipalities were getting up until starting now, next year it's going to increase, is they're at the same level right now in 2023 as they were in 1993. So they've been expected to do more with less for 30 years. Now, some of the townships in that funding are getting like $20,000 a year in their shared revenue allotment. Well, $20,000 won't pay the cost of their fire and EMS service that they're required to have. Even if they're contracting for that service and sharing it with multiple other governments, you're looking at hundreds of thousands of dollars. And at the same time, they don't have the ability to raise the tax levies to the level that they need to pay for those services, especially as they transition from a volunteer model to a full-time paid model. It's one thing to work with your neighbor to pay that $100,000 a year, whatever it costs to run that volunteer ambulance. It's another thing for that to then jump to $700,000.

And some of the things that we've seen happen just in the last year or two, as some of the smaller services have failed and gone out of business and they've had to contract with services, that cost might go from $100,000 to $400,000 or $500,000 for that local municipality overnight. They may, on a month's notice, be scrapping it to then go contract for another service at exorbitantly higher price than they've been used to paying. There's a lot of challenges that come with this, especially with those sudden collapses, or a lot of the local governing bodies don't understand actually what's going on with the service that's being provided to them on an everyday basis. They just know the ambulance comes. They haven't realized that it went from twelve volunteers running the place to four, and things like that.

Because one of the things that we've done really badly in the EMS profession is that when people ask how we're doing, we tell them we're fine. You're covering 24/7, 365 with four people, and we have services like that in Wisconsin. I know of one in particular that we're working with right now on a sustainability plan, which has four people, and they are covering their calls 24/7, 365, they're making it go. But they have recognized that that's not doable in the long term and are working on a better plan for the future to work themselves out of that. But what happens when you have four people and then somebody breaks an arm or somebody has a heart attack or they move and now you're down to three, and now you're going to have periods where you're out of service.

Andrew Nelson: Wow. Yeah. After completing your survey and analyzing the results you got, what recommendations were made for improving the reliability and sustainability of EMS in Wisconsin?

James Small: Well, there's a few things we need to work on. One is we have to find an ongoing recurring sustainable funding source for this. I think when people look at EMS, they think, “They do the ambulance call and they send the bill.” We all know that billing's not sufficient to cover the cost of EMS, especially in the rural communities that have a lower call volume. It might cover a quarter of the cost. It's not going to cover the full cost. So how do we get a more sustainable funding plan in place for these local governments to fund their ambulance services?

Other things that we looked at, we need to figure out sustainable recurring funding for developing the workforce. We know that we need to keep bringing people in and training them, but how do we get training to them? Access to training was one of the things that came up in our study where that was a significant issue. We had 13% of our services over an hour from their closest place to get certification training. So if you're trying to bring in volunteers, I think it's pretty unreasonable to bring somebody in, expect them to work their regular job eight hours a day, drive an hour to a training center, go to class for four hours, drive an hour home, and then get up the next morning and go back to work, and then do that 50 times to get their EMT license.

I think that's a huge barrier. One of the things that we're working on is how do we provide some kind of remote training so we can get training to everybody in a reasonable way and remove that barrier. One of the things that came with some of the legislative changes on workforce is that the state has a funding mechanism for EMS services called the Funding Assistance Program which has been around since the '80s. And it's been at about $2 million since 1988. That amount was increased to $25 million. So a significant amount of money, and that that can be used for training or capital purchasing. So you're looking at ambulance services going from allotment to maybe $4,000 or $5,000 a year to maybe $50,000 a year or more, which is going to make a significant impact on their ability to pay for training, especially if there's increased cost with like having to have smaller class sizes and things like that.

Because you're in a rural community and maybe you only have four people that are going to take a class. Well, now that becomes financially viable with this funding. And then the cost of capital, like ambulances and stuff, because that their funds can be escrowed from year to year and then used for major purchases. Another issue is just creating sustainable funding for technical assistance. That's another thing that we've identified as an issue with ambulance services, is that it's very challenging for service directors of small services to be educated in what they just took on. You know, a lot of them ended up in that role because nobody else wanted it, and maybe they didn't go to a meeting, so everybody voted them in and then they become in charge. There's a lot of obligations that come with running these services.

How do you get people educated in that? One of the programs that we run from our office is that we have a virtual-based program that's 12 hours of training on just the nuts and bolts of running an ambulance service. And we have a consulting company that has developed that training and administers it for us. And we offer it four times a year virtually. So they come into six online sessions. And we'll go over kind of the nuts and bolts of, “This is what EMS is all about. Here's how funding works, here's how to do a budget,” and so on. Because it's not unusual for me to run across situations where the service director doesn't know who owns their service. You know, “Are you a nonprofit? Are you a for-profit? Are you owned by a municipality? Are you owned by some kind of a joint partnership with municipalities?” And it's not unusual to find people who are running the services that don't even know that. The first time I had that happen, it blew my mind. But I've come to find that it's really common. And especially in the smaller service because their focus is on making the wheels turn, not on the administration of the department. So they're putting all their time and energy into making these wheels go, and they're approving people to come on their rosters and stuff, but they're not really understanding the obligation that came with that.

Another recommendation that we had was developing a system on of accountability that requires the municipalities to ensure that they have reliable ambulance service to access their public funding to provide those services. I think at the end of the day, when you look at why do we have these widespread issues in EMS, not just in Wisconsin, but across the country, it goes back to, the main issue is accountability. And there's been a lack of accountability all the way through the system, probably since day one. Your state governments haven't provided adequate funding to get it off the ground in the first place. They haven't provided adequate oversight in their state offices or licensing authorities. Our state office has like four employees. We have 18,000 providers. And between the ambulances and the EMR [emergency medical responder] services, we have about 800 services overall. It's not possible for four people to provide accountability to something that large. In contrast, the law enforcement system that's operated by the Department of Justice has 15 employees overseeing roughly 500 agencies and 12,000 providers.

So that's just a contrast on where the priorities have been given over the years. Lots of money went into the law enforcement system. Very little, if any, has gone into the EMS system. And then when you get into the local government, I know that there's local municipal governments that are making the conscious decision to stay with a service that's only providing maybe coverage half the time because it's significantly cheaper than the alternative. When you really don't have options with your finances, you have to make some really bad choices sometimes when you don't have any choices. So the local government isn't doing maybe some of the things they could be doing with borrowing or going to referendum, asking the voters to increase the funding to provide that service and so on, because they're just in this impossible position.

And we've got to remember too that our local elected officials, especially in the rural communities that don't have professionally trained administrators running the municipality, anywhere from three to seven members of your community that are being elected because they want to help with things. And then they're given no training, they're given no education on how things need to go or tools that they even have available to them. And then they're told to go out and do good things. And not surprisingly, it's hard to figure these things out and they just don't. So how do we do that? How do we get accountability to the services so that they're holding themselves accountable to make sure the staffing is appropriate? And if it's not, they're doing the right things to try to get staffing in a better spot.

Andrew Nelson: When you finished your study, you obviously weren't content to just let the results sit on the shelf. Can you tell us about how you made sure the results were shared widely and how your results and recommendations helped to inform policymaking?

James Small: We did a number of things with the study. First as we were going through all the data, we had some preliminary data that we knew was ready for release. And we released a one-page advocacy paper during the state EMS conference. So the state EMS conference was up in Green Bay. There's about a thousand providers a year that come to the conference. It's big, gets good attendance. And so, we put together just this one-page document of, “Here's some of the things we're finding,” and released them to the media. Because there was already a lot of media at this event. So there was a kind of a media push that came out of that starting with that event. We also were involved with the legislative advocacy day that the Wisconsin State Fire Chiefs and Wisconsin EMS Association and several other groups collaborate on.

That happened in the middle of March. We gave a presentation on the study results to that group during the orientation session for that. So we had 15 minutes in front of them. “Here's what it is.” We also provided each attendee a copy of the advocacy paper as they were going to be going over to the Capitol and meet with their local legislators. The day after the Advocacy Day, the Senate Committee on Rural Issues held a hearing on EMS. And we were the ones that kicked it off with a PowerPoint on the results of our study. So we launched that hearing and then we officially released the study the day after that. So they heard it first at the Capitol. It got an absolute ton of media attention.

We've had media outlets from across the country reach out wanting to know more about what we did. Lots of media. I think every legislator ended up with a copy of it. We were getting calls for technical assistance from legislators who wanted to meet one-on-one, talk about the study, talk about how it fit with things that they were hearing from their local leaders and so on. And it really became the driver for this increase in funding that we saw. There's an additional $240 million that got put into local government with that. But this really became the driver of it. We were the only ones with data at the table at the legislature. Nobody else had a study, nobody had any data. It was just like, “We want more money.”

The timing of this couldn't have been better at dropping it right into the budget discussion and saying, “Here's why local government needs it.” We've worked with our local advocacy or our statewide advocacy associations, and worked with the League of Municipalities which is very active. The Wisconsin Towns Association has partnered with us on some things too. So, I would be very surprised if at this point almost everybody in the state hasn't seen something relating to this study; it was so widespread in the media. I know it was really active in all the media markets, and I couldn't walk into an office at the Capitol without seeing it laying out on somebody's desk.

Andrew Nelson: When you put that hard work in to organize information about something like that that's so important, it's got to be very gratifying to see that kind of engagement with people who might have the power to pass some legislation that'll actually improve that situation.

James Small: And one of the things that we saw too with this is that all the partisan politics went away when it came to EMS. There wasn't anybody that didn't agree that there was a problem. There might've been some disagreement on what the solution is and what those solutions could look like. But you really saw the partisan lines go away on this issue.

The funding bill has already passed. 2023 Act 12, that passed in June. The money will start flowing from that next year into municipal budgets. So the funding part is started. One of the things that they did with the funding is that they tied that increased amount of the funding to the state sales tax. So Wisconsin has a 5% state sales tax. They took one point of those five points and tied it specifically to municipal funding. So as prices increase and people spend money on things, that amount of money available to the local municipalities, we'll move with that. So kind of an interesting way to look at funding, and a major departure from the way things have been done previously. They've increased the funding substantially. And one of the things that they did in that is that there's a disproportionately high amount of funding going to the smaller municipalities.

So our rural townships that historically were getting like $20,000 a year, they might now be getting $100,000 a year where municipalities with populations over 30,000 are getting a lesser amount. So there's a tiered system in place that really favors the smaller communities.

Andrew Nelson: Yeah. And that's a great example of policy change that you saw there in Wisconsin to support rural EMS. Do you have any thoughts on any other policy changes at either local or state or federal levels that could further alleviate the financial burden felt by communities trying to maintain EMS?

James Small: Well, we're seeing a number of things coming down the pipe. Fire and EMS programs are now part of the state apprenticeship program under the Department of Workforce Development. So they'd be eligible for certain grant funding and stuff, similar to electricians or things like that where you might see apprenticeships. You're seeing more EMS programs in particular, and some fire programs too, being brought into the high schools. There's a number of the technical colleges that are doing a dual enrollment program where kids, their senior year, will go to the technical college instead of the high school and can get fire and EMS training their senior year of high school as part of their high school diploma requirements. So there's a lot of different ideas like that, but they all require funding. Our Department of Public Instruction, which handles all the elementary and high schools, has seen this as a priority and is really pushing into this space, encouraging schools to be in this space.

You're seeing the technical college system partnering with them, that's those dual enrollment programs. So I think it's just kind of shifting that idea; maybe we need to try some things differently. And you're seeing players step up to do that. The dual enrollment programs have had really good attendance. I know where I live locally, they'd normally run one cohort of like 25 students. They had so many applicants this year that they doubled that and they still turn people away. They have 50 students right now in their dual enrollment program this school year.

Andrew Nelson: Your office provides technical assistance for rural EMS. What are some of the issues you're seeing that people need that assistance with?

James Small: It's kind of all over the board. Some of the technical assistance requests might be something that we can handle just in a matter of a phone call. It might be a question on developing a policy or needing a model policy for something all the way through to that. There's services that need to do a do-over. We're doing technical assistance with a number of different counties. So in Wisconsin, a county is not responsible for EMS service, but if they want to be responsible for EMS service, they have unlimited taxing authority to provide that EMS service countywide. So there's a number of counties that have just decided to step in and help their local governments by doing that. There's a lot of projects going on. Right now, we're involved with five. Five out of 72 counties that we're involved in.

In the rural communities, you might have a community or a county that's got eight different ambulance services that all aren't doing well. Well, let's have county government take that on, maybe be county employees. Because we do have several counties which are running full county-wide EMS with county employees, and they're doing very well with it. And it becomes a very cost-effective way of delivering that service and covering a large area because in some of these counties you're talking about covering 1,000 or 2,000 square miles. So there's some very large rural areas on a county-wide basis. But that's probably the biggest of the projects. And then working with local government on funding, that's been part of it too.

We're looking at some of the consolidation projects that are going on in regionalizations. So what regionalization is, is when you take multiple services that are contiguous to each other and then merge them together basically into one entity providing service over that entire area. Right now there's a regionalization going on up in the northern part of the state that there's four townships that each had their own ambulance. They're all having some level of distress with their ambulance service. So they're then going to consolidate those four into one entity that will then have two full-time staffed ambulances. So instead of four volunteer ambulances that are sometimes available, you'll have two available continuously. So that's a project based on reliability. The other thing that you'll save though is now instead of having four ambulances for your capital expenses, you'll have two. You won't be having a primary and a backup four times. You know, where there might be eight ambulances in the system, you might have three ambulances there. So there's a lot of cost savings that can come down the line.

But it also takes that political courage of those political bodies to sit down together and say, we're going to do this. And it's going to cost more money, but this is the right thing to do for the community. And that's hard for local elected leaders to do because they generally see their role there to make taxes as cheap as possible. Right? “So, I got elected to have low taxes.” “Well, no, you got elected to make sure that we're using the money efficiently and providing adequate service to the people. You know, we don't need a Cadillac, but at the same time, we need a car that runs.”

We'll get brought in to give like a second opinion on that. I've got a couple of those where they're putting together plans on it, doing budgets and stuff. So you'll look at that, go through and do a budget analysis and then give them back an opinion on, are you working with enough money or not? Because when you look at regionalizations, regionalizations don't happen to save money. Regionalizations happen on day one to improve reliability. You have multiple entities that are having some kind of a struggle with staffing. So you put them together and then you increase the budget. But municipality A maybe only has to increase theirs by 50% instead of 100%. So there's cost savings down the line from doing it yourself, but on day one, it still costs more, if that makes sense. And I think people tend to look at regionalization as being a way of saving money. And it does, but it's not direct. You're not going to see, “We spent $100,000 last year. Now we're going to spend $80,000. It's going to be, “We spent a hundred thousand last year and next year we're spending $200,000. But that would've been $300,000 had we not regionalized.”

I think that's part of the challenge too, is just working with the local elected officials too, and kind of walking them through that process and keeping them on point.

You know, I have a master's degree in public administration and I'm a certified public manager and have a good background in municipal finance. So I'm bringing that to the table and saying, “This is how we're going to pay for it,” and working through some of those issues. And then I think they realize that there's a lot of efficiencies to be found in some of their budgets, or they can do things, there's other tools available to them that they may not have even been aware of. And when we work through those things and then all at once, EMS becomes a lot more affordable.

Andrew Nelson: Maybe one of the most immediate, or the most obvious, benefits from that would be to streamline mutual aid efforts and provide even, consistent coverage.

James Small: Yeah, and in some areas too, you'll see where services are cross-credentialing. So, they'll share one person between two services where today they're going to respond for ambulance A and tomorrow it's going to be ambulance B or they might be available to both of them at the same time. Cross-credentialing is just a tool that I think helps buy time, but I have seen it abused to the point where it's kept things running to the point until it doesn't anymore. Because when you have this, say you have one person that's cross-credentialing between three services, and then they're not there anymore. Well, now three services now have lost that person's service and it maybe gives a false sense of security that they're more sustainable than they are because they were able to handle the call today until the person moved. And now they realize that this one person has been doing a lot of that.

One of the measures that we used in our study was, “How many people does it take to cover 80% of your call hours?” So, we know that it takes about 7.5 FTE if you have people working a 24 on, 48 off traditional full-time shift; that's about a 7.5 when you factor in relief factors and things like that. So what we were looking for was, “How many services are operating on six people or less?” And that was also 41%. Interestingly, when you go into the data, it's a different 41% that has this staffing shortage. There's some overlap, but it's not an exact duplication of one list to the other. But you're looking at 20% of your services operating on 80% of their hours are being done by three people or less.

Well, they might have 20 people on their roster, but there's only three people doing 80% of the work. That's not sustainable. You know, that's not a thing. And then we had another four to six that was like 21% of the services. So we had 41% total. We're operating on six or less doing that 14,000-and-some hours. It's 17,520 hours to run an ambulance for a year. So we used that 14,000 hour metric as the 80% to try to figure out what is it, how many people are actually doing the work? Because I think we all know in our organization, no matter what that organization is, you might have 50 people in it, but it's really like five people doing most of the work. And these smaller services are no different than that. So most of them will tell you that they have 20 people on the roster, but when it comes down to what's actually happening, that 80% metric is really predictive of how sustainable that is in the future. Because if you're at two to three people doing 80% of those hours, you literally are one person away from going completely out of service.

Andrew Nelson: Yeah. It's good to think beyond just what's working today and consider what you might have to do tomorrow, if even a relatively minor change occurs. It can have a huge impact on availability of services and sustainability. This study that you recently presented for the legislature was very impactful. What are some ways in which stakeholders can advocate for their communities?

James Small: Providers at the ground level need to be very honest with their governing bodies about what's going on. You know, this idea that, “There's only four of us making this thing go,” not that, “Hey, we're fine, we're handling our calls.” It's, “No, we've got to figure out a plan here and move forward,” because it's just not in our culture, in public safety to admit that things aren't going well, and not admit that there's a problem until there's a problem, right? So, I think that's the biggest thing.

And to maybe even do their own study, “What's going on internally?” When I've gone to work with individual services and I start asking them for data, it's not uncommon that they don't know what their data says. You know, they might know that they did 300 calls last year, but they don't know where their calls were. What's that call distribution look like? How many of your staff members handled those calls, and stuff like that? And start getting into understanding what their data tells them, because that data tells a story too. And that's going to help identify some of these issues. Like if you're using that 80% metric that's going to start telling you that, “Hey, we're in a position where we might not be sustainable going forward. We need to take some corrective action here.”

I think stakeholders, like community members that know that they're an issue, reaching out to their local legislators, reaching out to their local governmental bodies. I mean, ultimately this is a function of government and I think that really distinguishes it, at least in Wisconsin. Wisconsin doesn't have government-run hospitals. There's a couple of government-run mental health facilities, but as far as like hospitals, that's all privately run.

So healthcare is largely private in Wisconsin, so we're very distinguished from that. Being that we are a hundred percent a function of government for 911 ambulance. But I think the biggest thing is just being honest about what's going on. You know, the other thing is, we're our own recruiters for our agencies. So when we're out in the community talking to people and saying, “Hey, you know, we could use some more people. Hey, there's an EMT class coming up, maybe you'd be interested in that.” And being inclusive and being inviting and asking people to come in. That's how I ended up in this. My dad was on the fire department, and I was around the fire station a lot, and they had a class coming up and they said, “Hey, maybe you'd want to be in this.” And here I am talking to you 30 years later.

Andrew Nelson: Yeah, I suppose there are lots of people that would recognize the importance of having that service and they'd be willing to become part of the solution with volunteering. It just might not occur to a lot of people.

James Small: Yeah. I don't think people realize how out-of-hand some of these things are until the service collapses. That's been my take, going into some of the communities where this has happened, is they didn't realize how out-of-hand things were until it was done. And at that point, there's no good options left. You know, if we do this in a controlled way, there's all the options in the world. And I think another part of this too is understanding that there's not a cookie-cutter solution to this. If there was that silver bullet, we would've found it already, but there's good reason why there's thousands of communities that are having this issue across the country and we haven't found the solution for that community. So that's part of it too, when I go into work with a community to work on their EMS stuff that's one of the things I start out with is that there isn't a cookie cutter for this. You need to participate and you need to make choices on what's good for them, because I don't know, I don't know what's good for this community. I know there's lots of different ways to deliver this service, and one of them will get used, but I don't know which one.

I think the biggest thing is this is solvable. We're in a situation where this is a challenging issue, but it's solvable and it might cost money and it might be getting people to pivot and come into a career they might not have thought of coming into and things like that. But I know that there's ways to solve this, or it might mean two communities that don't like each other working together for the common good too. But there's solutions out there. We're smart people in the United States. We're educated. We put a lot of money into education, and I think collectively we'll find answers in each of these communities. It's just a matter of people understanding how big the issue is and having the will to solve it.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with James Small, the Rural EMS Outreach Director for the Wisconsin Office of Rural Health. Look in our show notes for more information about their work and visit for all things pertaining to rural health.