For years, EMS leaders have complained that nobody will fund innovation.
Want to start community paramedicine? Great idea. Who pays for it?
Want to treat appropriate patients at home? Sounds wonderful. Who pays for it?
Want to integrate EMS with primary care, behavioral health and telehealth? Fantastic. Please submit a proposal explaining how you’ll accomplish all of that with the money currently hidden somewhere between the station couch cushions.
Then along came the $50 billion federal Rural Health Transformation (RHT) Program.
CMS is distributing $50 billion over 5 years, with $10 billion available annually from 2026 through 2030. All 50 states received awards, and states are now using those dollars to strengthen rural healthcare, expand access, develop the workforce and create innovative models of care. For EMS, that funding is translating into opportunities involving community paramedicine, mobile integrated healthcare, treatment in place, workforce programs, technology and rural EMS sustainability.
There is, however, one small detail. This is federal money. And federal money generally arrives with more strings than the station Christmas lights.
| MORE: Grant funding demystified with Anya Otterson
The money is moving fast
RHT implementation is occurring at extraordinary speed. CMS announced state awards in late 2025; established an Office of Rural Health Transformation; and states are now rapidly moving hundreds of millions of dollars into grants, contracts, subawards and provider programs. CMS has also made clear that implementation will include ongoing reporting, oversight and accountability.
For EMS agencies accustomed to waiting several years for somebody to decide whether an ambulance payment policy should be studied, this pace may feel refreshing.
It should also feel slightly terrifying.
Many rural EMS organizations have relatively limited administrative infrastructure. The finance department may consist of the chief, someone at City Hall and a someone named Debbie who knows where all the receipts are.
Now we’re asking those organizations to administer healthcare transformation projects involving procurement, contracts, allowable costs, performance measures, data reporting and federal funding requirements.
What could possibly go wrong?Actually, quite a bit.
A grant award doesn’t become ordinary operating revenue simply because the money arrives. Depending on how a state’s RHT program is structured and whether an EMS agency is a subrecipient, contractor or other funded entity, there may be specific requirements governing expenditures, procurement, documentation, performance and reporting. CMS’s general grant guidance also makes clear that federal funds deemed owed following audits or other reviews can be subject to recovery. That doesn’t mean RHT recipients should expect a clawback, but it does mean documentation and compliance matter.
The practical lesson is simple: Someone will eventually ask what you did with the money. “Bought some stuff and started an MIH program” probably won’t be the preferred answer.
Compliance starts before you spend the money
The best time to build grant compliance isn’t when the auditor arrives. It’s before implementation begins.
Every EMS organization receiving RHT funding should be able to answer some basic questions:
- What exactly did we promise to do?
- What expenses are allowable?
- What procurement rules apply?
- What documentation must we retain?
- What outcomes did we agree to measure?
- Who owns each reporting responsibility?
- What requires prior approval?
- And what happens if the project changes?
That last question is important because healthcare projects rarely unfold exactly as proposed.
Maybe the technology vendor can’t deliver. Maybe the community paramedic you planned to hire doesn’t materialize. Maybe patient enrollment is slower than expected. Maybe the hospital partner changes leadership. Maybe that $80,000 software platform everyone loved during the grant application communicates with your ePCR about as effectively as two neighboring fire departments discussing mutual aid after a disputed structure fire.
Programs change. The mistake is changing the program and assuming the paperwork will catch up later.
Agencies need a process for documenting material changes, determining whether approval is required and preserving that authorization. The grant proposal isn’t merely how you win the money. It can become part of the operating specification somebody later compares to evaluate what you actually did.
The administrative framework doesn’t have to be complicated. Create a simple grant obligation matrix identifying each deliverable, deadline, responsible person, budget category, documentation requirement and performance measure. Establish accounting that clearly identifies RHT expenditures. Preserve procurement records, contracts, invoices and approvals. And document decisions while people still remember why they made them.
Because 18 months later, “Debbie remembers what happened” is not really an internal control.
“We completed 417 visits” isn’t an outcome
Compliance is only half the challenge. RHT is supposed to transform rural healthcare, not merely fund activity. Imagine the final report: “We completed 417 community paramedicine visits.” Great. But did anything change?
Did 911 utilization decline? Did ED visits decrease? Were hospital readmissions reduced? Did patients connect with primary care? Did access improve? Did the intervention cost less than the healthcare utilization it replaced? Did patients have better outcomes?
And perhaps most importantly: What happens when the federal money stops?
Every RHT-funded EMS initiative should really have two dashboards.
- The first measures compliance: expenditures, deliverables, deadlines and documentation.
- The second measures outcomes: patient utilization, access, clinical results, patient experience, system capacity, cost and sustainability.
Compliance asks, “Did we do what we promised?” Evaluation asks, “Did it work?” A successful program needs to answer yes to both.
That second question is especially important because these grants provide EMS with an opportunity to build the evidence needed for something the profession has pursued for years: sustainable payment for healthcare delivered outside traditional ambulance transportation.
If community paramedicine, treatment in place and mobile integrated healthcare reduce unnecessary ED utilization, improve access and lower total healthcare spending, document it. Those results may eventually be more valuable than the grant itself when EMS sits down with Medicaid programs, health systems, ACOs and commercial insurers to discuss permanent reimbursement. The grant should fund the experiment; the data should help fund what comes next.
Build the exit strategy on Day 1
RHT may represent one of the largest opportunities EMS has had to demonstrate that it is part of the healthcare delivery system rather than simply transportation to it.
But the speed at which that opportunity is being created also creates risk. Agencies are being asked to design programs, hire people, procure technology, establish partnerships and demonstrate results quickly.
The answer isn’t to slow everything down. It’s to build compliance, measurement and sustainability into implementation from Day 1. Because the worst outcome isn’t failing to win an RHT grant. It’s winning one, spending several years building an excellent program, discovering there is no sustainable payment model, failing to document what the money accomplished, and then receiving a letter asking whether some of the money needs to come back.
Nobody wants that letter. Especially Debbie.
Rural Health Transformation gives EMS a remarkable opportunity to demonstrate that mobile healthcare can improve access, reduce unnecessary utilization and create meaningful value for rural communities. Let’s make sure that 5 years from now, we’re talking about the programs RHT created, not the money somebody had to give back.
Additional resources:
- Medicaid Rural Health Transformation (RHT) Program
- CMS: Post-Award Reporting Requirements
- CMS Guidance for Preparing a Budget Request and Narrative
- EMS1 GrantFinder: Our suite of solutions gives agencies direct access to seasoned grant professionals—backed by over 500 years of combined experience—along with a comprehensive tailored grant database
- On-demand webinar: Grants Day — Your funding playbook. Get the insights, expert advice and tools to help your agency score big on grants
