RHTP implementation partner · Rural health transformation
Rural health systems, governance and policy
TPF works with states, counties, and regional partners to understand what is actually driving EMS fragility in rural and frontier communities — and to build the governance, policy, and financial frameworks that address it at the source.
Financial management and board governance
A governance design that a budget cannot carry is not a design. This is the part of the pillar that decides whether the rest of it survives, and it was until recently the least visible thing TPF does. It covers chief-financial-officer-level financial strategy, funding-model design, scenario and cash-flow modelling, budget development and monitoring, and financial reporting systems built for the people who actually have to make the decision, which in a rural service is usually a volunteer board or a county commission.
Alongside it sits nonprofit board development, governance training, and board facilitation. Many rural EMS organizations are governed by boards whose members joined to support an ambulance service and then found themselves responsible for a multi-million-dollar entity with federal reporting obligations. Training that board is not an add-on to the system work; it is frequently the intervention with the longest half-life, because the board is what remains after the consultant leaves.
TPF delivers this through its contract accounting and finance team, and it draws a clear line at the edge of its own competence. TPF supports preparation and board explanation. Audited financial statements, tax returns, and the opinions attached to them rest with the organization’s accountants. TPF says which is which rather than blurring it.
Free models that support this work, including staffing and schedule modelling and rural cost and revenue models, are on the financial modeling page. The named bench for this domain is on the capabilities page.
What drives fragility in rural EMS
Rural and frontier EMS systems are not struggling only because of too few paramedics. TPF’s approach starts from that structural reality. They are not struggling because local communities lack commitment. The problem is structural — governance, reimbursement, and infrastructure architecture that was never designed to sustain them.
In Colorado, 51 of 64 counties have ambulance unit requirements set by geographic coverage standards rather than call volume. That means the fixed cost of maintaining a paramedic available around the clock does not decrease regardless of how efficiently the system is managed. Maximum county-level consolidation — the recommendation most frequently offered as a solution — would close 13% of the structural funding gap. The remaining 87% is geography, payer mix, and the irreducible cost of readiness in low-density, high-distance service areas.
The Rural Health Transformation Program is the largest federal investment in rural health infrastructure in a generation. It allocates $50 billion over five fiscal years (FY2026–FY2030), administered by the Centers for Medicare & Medicaid Services (CMS) under Public Law 119-21.
The RHTP arrived in the same legislation that enacted substantial Medicaid cuts. It does not offset those cuts. Rural EMS systems that depend on Medicaid transport reimbursement will feel that tension directly.
TPF works with states and regional partners to develop those plans. The TPF team brings direct rural and frontier field experience to every engagement. Rural and frontier are geographic designations; austerity is an operational one. In practice, frontier EMS frequently operates in both — and TPF’s work accounts for that. Austere and wilderness care consulting is addressed on a dedicated page. Every engagement starts from local data, the regulatory environment, and community-specific factors. Free financial modeling tools are available on the financial modeling page. The goal is to position EMS systems to capture RHTP funding and build lasting structural improvements.
How TPF approaches a rural EMS engagement
System assessment and demand analysis
TPF starts with your CAD and ePCR data — call volume, acuity, response patterns, unit utilization, and repeat utilization. TPF validates and documents data limitations and builds findings from what the evidence will actually support. GIS-based demand analysis is included in all rural system engagements.
Financial sustainability and scenario modeling
TPF analyzes cost structure, payer mix, billing performance, and reimbursement gaps. Where GEMT is applicable, TPF assesses feasibility. TPF models the financial implications of deployment changes, alternative response programs, and new revenue categories — including what TIP/TAD reimbursement would mean for your specific payer mix.
Implementation roadmap
Findings lead to a phased, prioritized implementation roadmap with clear dependencies, KPIs, and realistic timelines. Deliverables are designed to be presented to agency leadership, county commissions, and state program officers — not to require translation before use.
Prior work in rural and frontier systems
TPF has conducted rural EMS system evaluations and sustainability assessments under multi-year contracts in Ohio, Nebraska, and Alaska. TPF has also supported system planning in Connecticut, Florida, Georgia, Idaho, Indiana, Maine, Michigan, Minnesota, Montana, New Hampshire, North Carolina, North Dakota, South Carolina, Washington, Wisconsin, and Wyoming.
Each of those engagements has informed how TPF approaches the next one. TPF brings locality-specific institutional knowledge to every engagement and can move faster on analysis and stakeholder engagement as a result.
RHTP partnership
TPF as your RHTP subrecipient or implementation partner
The Rural Health Transformation Program explicitly funds pre-hospital services, EMS delivery improvements, treat-in-place models, and rural health system redesign. TPF is positioned to support state agencies and rural health organizations as a subrecipient, technical assistance partner, evaluation partner, or implementation partner on RHTP-funded EMS and rural health system work.
TPF’s engagement structure adapts to what a state or program needs. TPF has experience with federal cooperative agreement compliance, CMS reporting infrastructure, and the governance design requirements that RHTP subaward recipients 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 CAD and ePCR data: call volume, acuity, response patterns, unit utilization, and repeat utilization. TPF pairs that with a structural assessment of governance, reimbursement, and operational architecture. The output is a written evaluation and implementation roadmap your agency can act on. Typical deliverables include a sustainability analysis, governance recommendations, a financial model, and — where relevant — a community paramedicine feasibility analysis. Engagements are scoped to the specific system. Initial consultations are 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 initiative (FY2026–FY2030) administered by CMS under P.L. 119-21. Pre-hospital EMS and EMS delivery improvement are explicitly named in the statute’s uses of funds, alongside community paramedicine and workforce development. All 50 states received RHTP awards for FY2026. States administer subawards to eligible entities including EMS agencies, regional advisory bodies, hospital systems, and FQHCs. TPF can engage as a subrecipient, technical assistance partner, or implementation partner under RHTP. See the dedicated RHTP page for full detail.
What is an ambulance desert?
An ambulance desert is a geographic area where residents face response times of 25 minutes or more for emergency ambulance service, or where no ground ambulance service operates at all. Research by TPF principal Dr. Yvonne Jonk and colleagues, published in Health Affairs, estimates that approximately 4.5 million Americans live in ambulance deserts — overwhelmingly in rural and frontier communities. The research has been cited by CBS News, PBS NewsHour, USA Today, and the Commonwealth Fund.
How does TPF approach EMS financial sustainability planning?
TPF’s financial analysis starts from the structural reality: in rural and frontier counties, the fixed cost of maintaining paramedic readiness around the clock does not decrease with call volume. TPF’s modeling addresses cost structure, reimbursement gap, subsidy requirements, and GEMT or Medicaid supplemental payment opportunities specific to your state. TPF has built financial models that have informed county commission negotiations, state legislative testimony, and federal grant applications. Free financial modeling tools are available on the financial modeling page. Custom analysis is available through a consulting engagement.
What states has The Paramedic Foundation worked in?
TPF has supported rural EMS system work in states across the country, including multi-year prime contracts with state offices in Ohio (active since 2017, $1.75M contract with the Ohio Department of Health FLEX EMS program) and Nebraska (2019–2026, $1.9M), and active engagements in Alaska (Matanuska-Susitna Borough EMS evaluation) and Wyoming (community paramedicine program development). Additional work has included South Carolina, Iowa, Georgia, Wisconsin, Indiana, Vermont, and others through consulting, stakeholder engagement, and technical assistance.
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Selected past performance
What a multi-year engagement looks like
TPF’s longest active engagement is with the Ohio Department of Health State Office of Rural Health under the federal Medicare Rural Hospital Flexibility (FLEX) program — a relationship that has run continuously since 2017 and is valued at $1,755,457. Over nearly a decade, TPF has functioned as Ohio’s standing rural EMS consulting partner: county EMS system assessments, statewide workforce surveys, community paramedicine protocol development, and sustainability consulting. The depth and duration of that relationship is a direct function of building work product Ohio can use — not reports that sit on a shelf.
Prior to Ohio, TPF served Nebraska DHHS as prime contractor from 2019 through January 2026 on a $1.9 million engagement spanning rural and frontier EMS system evaluations, regional governance design, and community paramedicine and triage-and-treat program development. Current active work includes the Matanuska-Susitna Borough EMS System Evaluation in Alaska and community paramedicine program development in Wyoming.
Discuss your system →Trying to understand what’s driving fragility in your system?
A conversation costs nothing. Tell TPF what you are seeing and what decisions you are trying to make. TPF will tell you honestly whether it can help.