RHTP implementation partner · Rural health transformation
Keeping emergency care available in rural communities
TPF helps states, counties, and regional partners keep emergency care available in rural and frontier communities. It finds what is actually driving a system’s fragility, then builds the governance, policy, and financial arrangements that address it at the source.
Financial management and board governance
A governance design that a budget cannot carry is not a design. This part of the work decides whether the rest of it survives. It covers funding-model design, grant and award financial administration, budget development and monitoring, and financial reporting 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 governance and board administration. 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. Equipping 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 officers and consultant bench, with a Finance Director appointment pending, 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 modeling 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, or because local communities lack commitment. The problem is structural: governance, reimbursement, and infrastructure that were never designed to sustain them. TPF’s approach starts from that structural reality.
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 the EMS parts of their RHTP plans. Every engagement starts from local data, the regulatory environment, and community-specific factors, and the TPF team brings direct rural and frontier field experience to it. Rural and frontier are geographic designations; austerity is an operational one. Frontier EMS frequently operates in both, and TPF’s work accounts for that. Austere and wilderness care is addressed on a dedicated page, and free tools are on the financial modeling page. The aim is for EMS systems to use RHTP funding to build structural improvements that last.
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 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, 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
How TPF supports RHTP-funded EMS work
The Rural Health Transformation Program’s permitted uses of funds include right-sizing rural delivery systems across pre-hospital and emergency service lines, and innovative care models. Whether a particular 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 under contract or as a technical assistance, evaluation, or implementation partner on RHTP-funded EMS and rural health system work.
Where federal funds are involved, the awarding agency designates TPF’s role, as a contractor or as a subrecipient, and that designation governs its treatment under 2 CFR Part 200. TPF has experience with federal cooperative agreement compliance, CMS reporting infrastructure, and the governance design requirements 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 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 program (FY2026 to FY2030) administered by CMS under P.L. 119-21. Its permitted uses of funds include right-sizing rural delivery systems across pre-hospital and emergency service lines, and innovative care models. All 50 states received RHTP awards for FY2026, and states fund eligible organizations, including EMS agencies, regional advisory bodies, hospital systems, and FQHCs, under their approved plans. 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?
In the Maine Rural Health Research Center’s 2023 study led by Yvonne Jonk, an ambulance desert is a populated area whose center lies more than a 25-minute drive from an ambulance station. This is a geographic access measure, not a measured ambulance response time. Using 2020 Census population data and ambulance station locations collected in 2021 and 2022, the study counted about 4.5 million people living in ambulance deserts across the 41 states with available data, about half of them in rural counties.
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. In Ohio, it has worked for the Ohio Department of Health under the federal 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), and consulting, stakeholder engagement, and technical assistance in South Carolina, Georgia, Wisconsin, Indiana, Vermont, and other states.
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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. Across 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.
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 →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 whether it can help.