1207: How States Are Rethinking Emergency Medical Services

JOHN SHEEHAN: 

This is Public Health Review Morning Edition for Thursday, September 17, 2026. I'm John Sheehan with news from the Association of State and Territorial Health Officials.

 

September is National Preparedness Month. Emergency medical services are evolving beyond the traditional model of responding to a 911 call and transporting patients to the emergency department. Maggie Nilz senior analyst for Preparedness at ASTHO, discusses how states are exploring new approaches to EMS, including how community paramedicine, mobile integrated health, telehealth, and treatment in place, while also working to address persistent workforce and funding challenges, particularly in rural communities. Maggie recently authored a new health policy update on the topic. Maggie Nils, welcome back to the show.

 

MAGGIE NILZ: 

Thanks for having me.

 

SHEEHAN: 

So, Maggie, when people think about EMS, emergency medical services, I think you know the basic conception is an ambulance ride to the hospital. But you write that that's changing. How?

 

NILZ: 

Yes, you're exactly right. Traditionally, when we think of EMS, we think of you know someone calls 911, an ambulance arrives, and that person is just transported to the emergency department. But state policy is increasingly creating more options between those steps. Things like community paramedicine, mobile integrated health, telehealth, treatment in place, and stronger system of care approaches. I think Hawaii is a really great example where the state is expanding its community paramedicine program to incorporate more mobile health and additional health telehealth capabilities for EMS, and we're really seeing policymakers wrestle, you know, with the underlying infrastructure that makes all of this possible. Whether that's EMS being recognized as an essential service, how it's funded, who can practice across state lines, and how those people are trained. Personally, as an EMT first, as an EMT myself, I've seen firsthand the needs that EMS encounters are often much broader than simply does this person need to go in the ambulance or not. And I think across states, we're seeing that policy is starting to think about EMS in that broader scope as well. Ultimately, the ambulance is still critically important, but transport doesn't have to be the only tool available.

 

SHEEHAN: 

Yeah. So walk us through some of those newer models you mentioned: community paramedicine, mobile integrated health treatment in place programs. What do what what does that entail, and how does how would someone's experience be different?

 

NILZ: 

Imagine that an older adult calls 911 because they're feeling unwell. Under the traditional model, EMS would assess that patient, get kind of a baseline understanding of their vitals and if there were, you know, any traumatic injuries or potential causes for illness, and then determine if they need additional care. And that primary additional care would be transport to an emergency department. In options like community paramedicine or mobile integrated health, there might be additional options. And so, if we start at you know, an EMT or a paramedic evaluating the patient, depending on state or local protocols, that EMT could potentially connect a patient with a clinician through telehealth, where they could be treated in the comfort of their own home. The patient might also be able to be connected with an alternative source of care rather than automatically going to an emergency department. So, if that older adult was in need of dialysis care, we might be able to connect them directly to a dialysis center as opposed to multiple steps through the healthcare system. And community paramedicine also takes a little bit more of a proactive, community-facing approach rather than just responding to something after it already becomes an emergency. So, public campaigns and outreach connecting people with social services and welfare supports to make sure that we're really doing preventative medicine ahead of time as well. These models depend heavily on state law, local protocols, and medical direction. But the idea is that the question becomes less where do we take this patient, and more? What does the patient actually need, and what's the safest way to connect them to it?

 

SHEEHAN: 

Yeah, another big challenge for EMS, you know, nationally, is EMS in rural locations. What are states? What are some states doing to address rural EMS challenges, and how could that impact things like response times, access to care, and ambulances?

 

NILZ: 

For someone living in a rural community, these policy conversations ultimately come down to a really basic question, which is: When I call 911, is there a staffed ambulance available to respond? Right now, we're seeing that. Rural systems are having extreme difficulty recruiting and retaining enough personnel to maintain reliable coverage, and that struggle isn't really abstract. It has really concrete, meaningful impacts for rural communities, which means things like longer response times, fewer available units, or relying on ambulances coming from much further away. We're seeing states tackle this in really different ways. So, for example, Illinois is adjusting their alternative rural staffing model to allow smaller systems to have more flexibility, to have different types of staffing, to include volunteer, part-time, and full-time staffing to help cover down and make sure that agencies do have enough personnel. Alternatively, Alabama's approaching the problem through training and retention by reimbursing training for people who commit to serving in state, and as well, they're establishing a commission to actually analyze and gather data on rural EMS coverage, financing, and workforce barriers, and then West Virginia has got kind of another part of the equation as well, where they've created some dedicated EMS funding that includes support for training and mental health treatment for EMS personnel as well. I think the challenge is that there isn't one singular rural EMS problem, so there's not one singular solution either. So states are really kind of looking across a bandwidth of staffing, training, retention, funding, and different service models.

 

SHEEHAN: 

Sure. And as you see how states are addressing these problems, where do you see EMS going in the next few years? How is it going to evolve?

 

NILZ: 

I think we'll see EMS continue to move beyond what we would consider the traditional exclusive transport model to a broader continuum of care. One of the challenges that states are confronting through policy is that EMS training, licensing, and scope have developed differently across jurisdictions, and as EMS is asked to do more, policymakers are working to ensure that the workforce and the regulatory infrastructure can support that expanded role. I also think data is going to become increasingly important in this conversation. If states want to make decisions about workforce shortages, response times, rural coverage, and alternative care, they need to be able to understand what's happening across their EMS system, and that's where we're starting to see some of these studies and commissions come out where policymakers are really trying to get into the nitty-gritty of understanding what truly is impacting EMS right now. I think five or 10 years from now we'll still see ambulances responding to emergencies. I don't think that'll change, but we'll increasingly see EMS as an entryway into a much broader system of care.

 

SHEEHAN: 

What do you want listeners to take away or learn about EMS services in their own communities?

 

NILZ: 

So I encourage people to learn how EMS actually works in their own community. For me, I continue to maintain my EMT certification, as I feel like it really grounds my own preparedness work and understanding of what's happening on the ground. And so I think it's really helpful for people to make those connections and understand, you know, who is providing the service in their community? Is it considered an essential service? And what challenges does that local system face? Do they offer some of those community paramedicine or alternative programs on an individual level? You know, I think it's great to see people learn CPR, know how to use an AED, and understand when and how to call 911, and think about what information responders might need. You know, personal preparedness does so much in being really, truly a part of that emergency care system. And I think, you know, preparedness isn't just something that happens during a hurricane or a major disaster. It also means having strong everyday emergency care systems and understanding how to use that and how to support that system in your own community.

 

SHEEHAN: 

Well, Maggie Nilz, thanks so much.

 

NILZ: 

Thank you so much.

 

SHEEHAN: 

Maggie Nilz is a senior analyst for Preparedness at ASTHO.

 

ASTHO is pleased to announce a funding opportunity to support up to three state and territorial health agencies in implementing activities that advance their Long COVID priorities and contribute to the growing body of knowledge and lessons learned across jurisdictions. Through this opportunity, awardees will implement strategies to address jurisdiction-specific needs, like strategic planning, resource development, public or provider education, and other activities that strengthen Long COVID response efforts. Find out more at the link in the show notes.

 

State and territorial health agencies are uniquely positioned to support community-driven prevention work, especially where issues like adverse childhood experiences, suicide, overdose, and mental health-related concerns intersect. The challenges that occur at the intersection are linked across the life course and often compound each other. Early adversity can increase the risk of substance use, mental health challenges, suicidal behavior, and overdose later in life. Learn more about partnering with community-based organizations to prevent youth substance use, part of ASTHO's Voices from the Field series, at the link in the show notes.

 

This has been Public Health Review Morning Edition. I'm John Sheehan for the Association of State and Territorial Health Officials.