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Home > Topics > EMS Management
August 12, 2014

Volunteer EMS 'hanging by a thread' in rural Ill.

A downturn in the economy and increased demand for quality health care have have rural providers considering changes

Laura Nightengale
Journal Star, Peoria

TREMONT, Ill. —  What started out as a part-time volunteer gig for flight nurse Anne Zuercher grew to demand up to 250 hours per month when the volunteer ranks dwindled for her small town's ambulance service.

Zuercher has donated 33 years to Rescue 702, Tremont's volunteer emergency medical service. She knows that despite their best recruitment efforts the staffing void may be too great to be filled.

"In two years it won't be (an all-volunteer service) just because we're having trouble getting volunteers to commit," Zuercher said.

Rescue 702 has community support, at least financially, Zuercher said -- the ambulance service's fundraising events are well attended -- but few residents are willing to donate time, so the service has formed a committee to examine replacing daytime volunteers with paid staff.

A decade ago, volunteer ambulance services thrived, especially in rural communities where pride and volunteerism were strong, but a downturn in the economy and increased demand for quality health care have changed the business model for rural EMS providers.

As training officer, Zuercher helps volunteers complete the months-long certification process

cess to become an emergency medical technician, but many just don't stick around long after.

"I think in general people are just busier and don't want to commit to anything else," Zuercher said. "They last maybe two years on the rescue squad, then they move on or get burned out, lose interest."

Rescue 702 isn't unique in its struggles. Its longevity sets it apart from the many EMS providers that have forgone the volunteer model in favor of more reliable professional services.

Jack Fleeharty, who oversees the operations of the state's nearly 700 ambulance providers as EMS and Highway Safety Division chief for the Illinois Department of Public Health, said that while statewide statistics aren't monitored, he believes filling the ranks of volunteer agencies while meeting the demands of the community is a challenge in Illinois and nationwide.

"It's all about resource limitation," he said. "That's probably the determining factor on whether a volunteer service can provide the level of care that a community wants or whether a volunteer service has the funding necessary to provide that care."

A dying breed

EMTs like Rosie Alig, 71, and volunteering for Emergency 116 in Metamora, are a dying breed.

Alig first enlisted with the ambulance service 30 years ago, when the youngest of her seven children was just 3 years old, a commitment she knows was only possible because of the support of her large family.

- "I've walked out on Thanksgiving dinners. I cooked, put it on the table and left. Know what I came home to?" she said. "Dishes. You've got to learn to just drop and run."

Today Alig serves as one of the directors for Emergency 116, which two years ago switched from a volunteer to a partially paid service after voters approved tax dollars to support the not-for-profit agency's budget.

The EMS agency shares firehouse space with Metamora's all-volunteer fire department, where the only staff are the professional paramedics who work the ambulances by day. At night, Emergency 116 reverts to a hybrid volunteer model, where EMTs can record the hours spent on a call for a small wage, though some are willing to forgo even that benefit.

"If they want to donate the time, that's fine," Alig said. "And a lot of us donate a lot of time that we don't ever turn in just because we're dedicated to Metamora ambulance."

Emergency 116 receives nearly $210,000 annually in taxes, but the larger portion of its revenue comes from service fees collected after patients are billed for services, said Bob Murphy, president of the three-member Emergency 116 ambulance board.

While the business model has shortfalls -- over half of the agency's calls are to Snyder Village, a local retirement community, and Medicare reimbursements only cover a portion of actual costs -- it is sustainable, while relying on donations of time and money was not.

"You have to be able to have a pulse as things change. You have to have the ability and flexibility to change as the need arises," Murphy said.

When Dr. Matt Jackson took over in 2005 as the director of the Peoria Area Emergency Medical System, which monitors the day-to-day functions of the area's emergency medical services, about one-third of the nearly 70 agencies were volunteer, staffed by EMTs and first responders accepting no pay.

Today very few of those operate as "pure" volunteer agencies. They may employ paid paramedics during the day and use volunteers to cover low call volume at night, but even those volunteers are often paid a small sum per call. The volunteer EMS model still exists, he said, but it is just "hanging by a thread."

The slow decline of volunteer agencies started in Illinois in 2006 when a test key was leaked and the low-level EMT Basic exam was compromised.

Until a new test could be created, all EMTs, including those seeking recertification, had to take a more advanced exam resulting in months-long delays.

"Volunteer agencies weren't able to fill their ranks because people were failing and failing," Jackson said. "And they're not getting paid to do this, so they just quit."

- If the compromised exam was a blow to volunteer agencies throughout the state, the economic downturn beginning in 2007 was a kick while they were down.

Folks weren't willing to take an unpaid job, and more of the homemakers like Alig, who kept volunteer agencies running, left their on-call posts in the home for the workplace.

Young families hit hard by the recession were the backbone of many volunteer services. A 2011 national EMS assessment showed that 70 percent of EMS providers, volunteer or professional, were between the ages of 20 and 49.

"I think those demographics (of rural communities) have really shifted," Fleeharty said. "I think you have more two-income families that are dependent on that today, and you don't have this group of people in a volunteer community who can fill that void."

Volunteer ambulance services may be going away, but often they're going through the ballot box. As more agencies push for tax-based revenue, many communities are willing to pay for quality ambulance care. Emergency 116's referendum passed in 2012 with 78 percent of voters choosing to create a tax to fund the service that allowed for an upgrade to paramedic service.

A higher level of care

For many, the shift from an all-volunteer to a paid or partial-paid model coincides with an upgrade in services when highly trained professionals take the place of part-time volunteers.

While the nostalgic, take-care-of-our-own attitude lives on in some small communities, the demand for quality health care prevails. The volunteer services that they know and love often can't keep up with people's needs.

"People's expectations of health care are very high, and people expect health care to be delivered in a very professional way with a very high medical standard," Fleeharty said. "And it should be because that (quality) is available and that education is available."

The Spring Bay Fire Protection District is one of the last all-volunteer fire and EMS agencies in central Illinois adhering to the grassroots business model, though it isn't immune to what Fire Chief Dennis Perry calls "the daytime crisis" brought on by a lack of volunteers available to fill slots while many residents are at work.

Today, college students home for the summer fill in, but Perry is launching an aggressive direct-mail recruiting campaign to bulk up the group of 30 volunteers, who average about six hours per week on the job.

While the agency might resort to paying part-time EMTs until the new recruiting class is trained, it's only a temporary fix. They have a volunteer model that works, Perry said, and have no plans to abandon the low-cost service.

- "The easy thing to do in the volunteer service is to start paying people," Perry said. "Within about two years they're paid 24/7, and you have no volunteers at that point. We want to avoid that."

Because Spring Bay is fortunate to be insulated by paid paramedic services, such as in nearby Germantown Hills, the village has the benefits of Advanced Life Support without the cost, which Perry estimated might demand $200,000 to $400,000, in addition to the $280,000 currently collected through a fire tax.

"I have ALS at my fingertips. I have ALS with a radio call. Does it make sense to pay paramedics to sit in Spring Bay and have all that cost associated with advanced life support when I can intercept with any of those agencies and have a paramedic on my scene, in my ambulance within minutes?" Perry said, adding the department handles about 300 medical calls each year.

"I don't think that the citizens should have to pay for that level of service when I have it available to them at the drop of a hat."

The demand for an increased level of emergency medical care is universal. In metro areas such as Chicago more emergency medical services are expanding and adding specialized services to meet the demands of increased populations, where paramedic is often the minimum level of training required.

Even the Peoria and East Peoria EMS market is "paramedic-saturated," said Jackson, Peoria Area Emergency Medical Services director.

And the increased level of care doesn't have much of an effect on patient bills. Whether an on-call, Basic Life Support agency responds to your 911 call or a more specialized critical care ambulance comes to the rescue, your ride to the hospital is likely to top $1,000.

"Most volunteer squads charge what they can to get Medicare reimbursements," Jackson said. "You charge the going rate or don't charge at all."

Eighty-five percent of EMS calls are non-life-threatening, said Kevin McGinnis, rural EMS program manager for the National Association of State EMS officials. So more often than not, an EMT Basic could provide sufficient care.

The questions facing volunteer services include what could be the cost of employing paramedics part time or full time, and whether the services need paramedics at all.

McGinnis said it's a gamble. When "the big one" hits -- a heart attack, diabetic emergency or severe injury -- most people expect to meet a paramedic somewhere between the 911 call and the hospital. EMT basics don't have cardiac monitoring capabilities nor can they insert an IV.

"The farther away you are from a hospital the more you are going to benefit from having a higher level paramedic respond to you. The paramedic paradox is the farther away you are from the hospital, the less likely you are to have that response," McGinnis said.

McClatchy-Tribune News Service
©2014 Journal Star (Peoria, Ill.)

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