Rural Health Transformation Program partner · Rural EMS systems
Keeping rural emergency medical services running
The Paramedic Foundation (TPF) helps states, counties and regional partners keep emergency medical services (EMS) running in rural and frontier communities. TPF finds what is really putting a local system at risk. Then it builds the governance, policy and funding plans that fix the cause at its source.
Why rural EMS systems struggle
Rural and frontier EMS systems struggle for structural reasons. Their governance, payment rules and infrastructure were never designed to sustain them. The cause runs deeper than a shortage of paramedics or a lack of local commitment. TPF’s approach starts from that structure.
In 51 of Colorado’s 64 counties, geographic coverage standards set how many ambulance units a county needs, whatever its call volume. So the fixed cost of keeping a paramedic ready around the clock stays the same, however well the system is run. The fix most often offered is to merge services at the county level. Even the fullest merger would close only 13% of the structural funding gap. The other 87% comes from geography, the mix of payers, and the cost of being ready where people are few and distances are long. No one can cut that cost.
The Rural Health Transformation Program (RHTP) is the largest federal investment in rural health infrastructure in a generation. It provides $50 billion over five fiscal years (FY2026–FY2030). CMS runs it under Public Law 119-21.
The RHTP came in the same law that made substantial Medicaid cuts, and it does not make up for them. Rural EMS systems that rely on Medicaid payment for transport will feel that strain directly.
TPF works with states and regional partners on the EMS parts of their RHTP plans. Every project starts from local data, the rules in force and the needs of the community. The TPF team brings direct rural and frontier field experience. Rural and frontier describe geography, while austere describes operating conditions. Frontier EMS often works under both, and TPF’s work accounts for that. Austere and wilderness care has its own dedicated page, and free tools are on the financial modeling page. The aim is for EMS systems to use RHTP money for structural improvements that last.
How TPF approaches a rural EMS engagement
System assessment and demand analysis
TPF starts with your dispatch and patient care data. That means computer-aided dispatch (CAD) records and electronic patient care reports (ePCR). TPF looks at call volume, how sick patients are, response patterns, how often units are used and how often the same people call again. It checks the data, writes down its limits and draws only the findings the evidence supports. Every rural system project includes demand mapping with a geographic information system (GIS).
Financial sustainability and scenario modeling
TPF studies cost structure, the mix of payers, billing performance and gaps in payment. Where Ground Emergency Medical Transportation (GEMT) payments apply, TPF checks whether they are workable. TPF models the money side of changes in deployment, alternative response programs and new kinds of revenue. That includes what payment for treatment in place (TIP) or transport to an alternate destination (TAD) would mean for your mix of payers.
Implementation roadmap
The findings lead to a roadmap in phases, with priorities, dependencies, key performance indicators (KPIs) and realistic timelines. Agency leaders, county commissions and state program officers can use it as written.
Prior work in rural and frontier systems
TPF has conducted rural EMS system evaluations and sustainability assessments under multi-year contracts in Ohio and Nebraska, and is performing an EMS system evaluation for the Matanuska-Susitna Borough in Alaska. TPF has also supported system planning in Connecticut, Florida, Georgia, Idaho, Indiana, Maine, Michigan, Minnesota, Montana, New Hampshire, North Dakota, South Carolina, Vermont, Washington, Wisconsin, and Wyoming.
Each project has shaped how TPF approaches the next. TPF brings what it knows about each place to the work. As a result, it can move faster on analysis and on working with stakeholders.
Funding the plan and supporting the board
A plan for rural EMS works only if the budget can carry it. This part of the work decides whether the rest survives. TPF designs funding models, manages the finances of grants and awards, and builds and tracks budgets. It also writes financial reports for the people who make the decision. In a rural service, that is usually a volunteer board or a county commission.
TPF also supports nonprofit boards. Many people join a rural EMS board to support their ambulance service. They then find themselves running a multi-million-dollar organization with federal reporting duties. Training that board is part of the system work, and its effect often lasts longest. The board is what remains after the consultant leaves.
TPF does this work through its officers, its Finance Director and the specialists TPF calls on. TPF helps prepare financial information and explain it to the board. Audited financial statements, tax returns and the opinions attached to them stay with the organization’s own accountants. TPF keeps that line clear.
Free models that support this work are on the financial modeling page. They include staffing and schedule models and rural cost and revenue models. The specialists TPF calls on for this work are named on the capabilities page.
RHTP partnership
How TPF supports RHTP-funded EMS work
Under the RHTP, states may use funds to resize rural care systems, including pre-hospital and emergency services. They may also fund new models of care. Whether a given EMS proposal can be funded depends on the state’s approved plan and the terms of its solicitation. TPF supports state agencies and rural health organizations on RHTP-funded EMS and rural health work. It can work under contract or as a technical assistance, evaluation or implementation partner.
Where federal funds are involved, the awarding agency designates TPF’s role, as a contractor or as a subrecipient. That designation governs its treatment under 2 CFR Part 200. TPF has experience with federal cooperative agreement compliance, CMS reporting systems, and the governance design that RHTP-funded programs are expected to meet.
Learn about RHTP partnership →About rural EMS system design
Common questions
What does a rural EMS system evaluation from TPF involve?
A TPF rural EMS system evaluation begins with your dispatch (CAD) and patient care report (ePCR) data. TPF looks at call volume, how sick patients are, response patterns, unit use and repeat calls. It adds a review of governance, payment and how operations are set up. The result is a written evaluation and roadmap your agency can act on. Typical deliverables include a sustainability analysis, governance advice, a financial model and, where it fits, a study of whether community paramedicine would work. Each project is scoped to the system. A first consultation is free.
What is the Rural Health Transformation Program and how does it fund EMS?
The Rural Health Transformation Program (RHTP) is a $50 billion, five-year federal program (FY2026 to FY2030). CMS runs it under P.L. 119-21. States may use the funds to resize rural care systems, including pre-hospital and emergency services, and to fund new models of care. All 50 states received RHTP awards for FY2026. States fund eligible groups under their approved plans. These include EMS agencies, regional advisory bodies, hospital systems and Federally Qualified Health Centers (FQHCs). TPF can work under contract with a state or as a technical assistance, evaluation or implementation partner. Where federal funds are involved, the awarding agency designates TPF’s role. See the dedicated RHTP page for full detail.
What is an ambulance desert?
The Maine Rural Health Research Center published a 2023 study led by Yvonne Jonk. It defines an ambulance desert as a populated area whose center lies more than a 25-minute drive from an ambulance station. The measure is drive distance to a station. It does not measure how long ambulances actually take to respond. The study used 2020 Census population data and ambulance station locations collected in 2021 and 2022. It counted about 4.5 million people living in ambulance deserts across the 41 states with available data. About half of them were in rural counties.
How does TPF approach EMS financial sustainability planning?
TPF’s financial analysis starts from one hard fact. In rural and frontier counties, the fixed cost of keeping paramedics ready around the clock does not go down when call volume does. TPF’s models cover cost structure, the payment gap, the subsidy needed, and the GEMT or Medicaid supplemental payments open to your state. TPF has built financial models that have informed county commission negotiations, state legislative testimony and federal grant applications. Free tools are on the financial modeling page. Custom analysis is available through a consulting project.
What states has The Paramedic Foundation worked in?
TPF has supported rural EMS system work in states across the country. In Ohio, it has worked for the Ohio Department of Health under the federal Medicare Rural Hospital Flexibility (FLEX) program since July 2016, across two contracts. In Nebraska, it served the Department of Health and Human Services from 2019 to January 2026 on an engagement valued at about $1.9 million, and has been the department’s prime contractor for Rural Health Transformation Program work since August 2026. In Alaska, it is performing an EMS system evaluation for the Matanuska-Susitna Borough. Earlier work includes community paramedicine programs for the Wyoming Department of Health (2018 to 2024). TPF has also given consulting, stakeholder engagement and technical assistance in South Carolina, Georgia, Wisconsin, Indiana, Vermont and other states.
To find out what is putting your system at risk, start a free conversation →
Selected past performance
What a multi-year engagement looks like
TPF’s longest-running relationship is with the Ohio Department of Health State Office of Rural Health and Primary Care under the federal Medicare Rural Hospital Flexibility (FLEX) program. It began in July 2016 and has run across two contracts. The current contract has been active since February 2019, and $1,755,457 in orders has been placed against it. For a decade, TPF has been Ohio’s standing rural EMS consulting partner. The work has included county EMS system assessments, statewide workforce surveys, community paramedicine protocols and sustainability consulting. The relationship has lasted because TPF builds work Ohio can use, rather than reports that sit on a shelf.
TPF also served Nebraska DHHS as prime contractor from 2019 through January 2026 on an engagement valued at about $1.9 million, spanning rural and frontier EMS system evaluations, regional governance design, and community paramedicine and triage-and-treat program development. Current work includes the Matanuska-Susitna Borough EMS System Evaluation in Alaska and, since August 2026, TPF’s prime contract with Nebraska DHHS for Rural Health Transformation Program community paramedicine and regional EMS work.
Discuss your system →Talk to TPF about what is straining your EMS system
A first conversation costs nothing. Tell TPF what you are seeing and what you need to decide. TPF will tell you whether it can help.