The Northern Michigan Center for Rural Health met with Leslie Hall, Executive Director of the Michigan Rural EMS Network (MiREMS) to get her input on the state of EMS in rural Michigan. Here is her #MiEMSstory.

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The Michigan Rural EMS Network (MiREMS) was established to provide support to EMS agencies and professionals by providing outreach designed to address challenges responding to the needs of rural Michigan communities. MiREMS evolved from the Huron-Sanilac EMS Network, a task force started with seed money from the Michigan Center for Rural Health, with the goal to improve recruitment and retention in the two counties. Leslie Hall was hired as  Executive Director in 2007 and, based on the success of the work in Huron and Sanilac counties, it was agreed that a statewide agency dedicated exclusively to rural EMS was needed. In 2012, MiREMS received funding from the federal Office of Rural Health Policy, Health and Human Services to develop the statewide network, and obtained nonprofit 501(c)(3) status.

“When it comes to addressing the challenges of EMS in rural Michigan, especially recruitment and retention, one of the most critical considerations really comes down to developing good leadership,” Hall said. “If we create a culture that stresses the importance of strong leadership, I think that will result in improvements which lead to more satisfied crew members who are more likely to stay longer, and who will then help recruit new members.

Hall has worked extensively on initiatives throughout the state of Michigan to improve rural EMS, including within the Upper Peninsula.

MiREMS is in the planning process to develop regional field offices across Michigan. In the U.P., there will be a location in Pickford as well as in Baraga, with the goal to have them operational in mid-2022. These offices will allow for local training and technical assistance for providers and agencies. They will also house an equipment trailer that can be loaned out for use by instructors or agencies for various education programs. MiREMS has also received funding to support mental health education and other support for medical first responders in the U.P. through these field offices.

MiREMS has piloted two different U.P. needs assessments, one focusing on challenges of rural EMS and fire agencies and another focused on identifying concerns impacting EMS and fire department personnel. MiREMS is also the lead agency for the Beyond the Save consortium, an initiative that has a mission to bridge gaps between the behavioral health system and emergency medical care, engaging first responders in the identification, treatment, and referral of substance use disorders to reduce deaths from overdose in the U.P.

“Through community outreach and education, Beyond the Save is working hard to reduce the stigma that’s associated with substance use disorders, specifically those who have experienced overdose and have had repeated overdose.” Hall said.  “There is an extraordinary amount of stigma both in the community and among providers.”

Read on for more of Leslie Hall’s first-hand account of working in rural EMS.

Q&A

What do you think is one of the most crucial issues affecting EMS systems in rural Michigan communities? What are some steps that can be taken to improve this issue?
I think the most critical piece of improving EMS systems is the ability to ensure timely and adequate EMS response, which is dependent on sufficient staffing, improved funding opportunities, and reimbursement for EMS service.

When it comes to recruitment and retention of EMS professionals in rural areas, what are steps that can be taken to improve the current situation?
We often talk about recruitment and retention as if they are one and the same but they are two distinctly different issues. Recruitment is an ongoing process and improves when it is integrated as part of the agency culture. Rural EMS agency leaders often don’t have the time, personnel or resources to implement a robust recruitment program. Seeking opportunities to promote the agency to the community by developing relationships with local media, engaging local officials and legislators, and participating in community events can all be helpful. Often, word of mouth from satisfied crew members is the best form of recruitment.  Retention can be improved by thorough vetting of new hires, transparency about the nature and stressors of EMS, improved wages and benefits, support for mental and physical health, an agency culture that promotes a work/life balance, crew input into agency operations, opportunity for a career ladder, and crew recognition programs. Many means of improvement require adequate funding. Agency leadership can engage with legislators in order to educate them about the need for improved funding and reimbursement.

In your experience, what are some common misconceptions or lack of information about the EMS system and EMS personnel that are unique to rural areas?
Among people who reside or vacation in rural Michigan, there is an expectation that when a 911 call is placed, an ambulance will respond in 10 minutes or less. The reality is that 20 to 40 minutes is not unheard of in rural areas. It’s a common misconception that the responding agency is going to be at the Advanced Life Support level of care, which is not always the case. Depending on the license level of the local agency, a basic life support agency may respond and then intercept with advanced life support if needed. There is also misunderstanding among the general public about the amount of education required for individual EMS licensure, the level of skills that EMS professionals possess, as well as the scope of services they can perform. There is a mindset that these professionals are ambulance drivers. They are highly trained medical professionals who provide many of the same interventions as an ER physician, but they provide care in much more challenging environments.

How has the current pandemic affected the EMS situation in rural Michigan? 
Some agencies were not prepared for something on this level –– they were not prepared for the demand in PPE and supplies, and the impact of the pandemic on crew mental health.

Thinking back to 2020, the initial required response was that EMS should avoid transport of patients to hospitals whenever possible. That put EMS agencies in a difficult financial position because Medicare and Medicaid require transport in order to reimburse for services, and often commercial services follow Medicaid and Medicare policy. Decreased hospital transport results in significant loss of revenue for these agencies.

Personnel shortages were exacerbated during the pandemic. In a system that is already challenged with shortages there is little room for providers who become sick and must quarantine. This has put more stress on an already stressed system. I believe that over the coming months and years we will witness the impact of the additional physical and mental stress on EMS as a result of the pandemic.

You’ve worked on past initiatives in the Upper Peninsula. Can you tell us about your experience working on initiatives specific to the area?
In addition to those specifically mentioned above, Beyond the Save provides Mental Health First Aid for Fire/EMS classes and has developed resource packets for EMS to leave behind when responding to a substance misuse call.  MiREMS has an initiative called MiResCu, the Michigan Resuscitation Consortium, which we implemented in several areas of the Upper Peninsula. MiResCu is a cardiac resuscitation initiative that includes high performance CPR training for first responders and placement of AEDs in rural communities, with the goal of reducing deaths and improving outcomes from cardiac arrest. We have also been a longtime supporter of the U.P. EMS conference and have sponsored education sessions and provided instructors for the past several years.

When it comes to substance use education, including training (EMS) personnel, and community engagement, what have you found working in rural communities?
Some interesting findings from the aforementioned rural needs assessment is that of those who responded, 76% of EMS professionals indicated they have experienced an increase in mental health calls and 87% said they had seen an increase in substance use calls. A few other interesting findings from that assessment: less than 50% of first responders who responded to the survey felt their training prepared them well for mental health calls, more than 60% were interested in training related to behavioral health topics, 65% reported experiencing critical stress, and 14% had thought about suicide. Those are concerning numbers.

MiREMS programming is developed based on results from needs assessments and surveys by professionals and agencies, and on strategic planning from our board of directors. We seek funding that will support those programs while ensuring our programs are needed and in rural Michigan.

What is your connection with the Northern Michigan Center for Rural Health? How does this partnership benefit your work or how may it benefit in the future?
MiREMS has had a longstanding and mutually supportive relationship with the Michigan Center for Rural Health and that has continued with the development of the Northern Michigan Center for Rural Health. Prior to joining Northern Michigan University as the Director of the Northern Michigan Center for Rural Health, Elise Bur and I worked together under the Rural Community Opioid Response Program initiative of the federal Office of Rural Health Policy, which funds the Beyond the Save initiative.  Elise and I meet monthly with Andrea Abbas (EMS Programs Manager, Mich. Center for Rural Health) to keep one another informed about activities we’re working on and to identify opportunities for collaboration. I also participate in the Center’s EMS subcommittee.

The relationship has been beneficial in providing opportunities to leverage resources, whether in funding or capacity. It has been helpful to identify opportunities and look at ways we can collaborate on initiatives and create a greater impact by working together.  We share a common goal and have laid the foundation for a great working relationship well into the future.

Anything else you would like to add?
The Michigan Rural EMS Network currently has a partnership with the Northern Michigan Fire Chiefs Association. We have funding through FEMA’s Safer program to work on recruitment and retention in the Northern Michigan Fire Chiefs Association service area.  We have completed a comprehensive needs assessment, and we are developing a robust marketing campaign and providing technical assistance with fire departments to equip them to implement an effective recruitment and retention initiative. We have applied for FEMA SAFER funding to duplicate this work in the U.P. and hope to receive news of an award in late summer.

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The Northern Michigan Center for Rural Health seeks to improve the health and well-being of Upper Peninsula residents and communities by developing collaborative partnerships that enhance the access and availability of affordable, quality healthcare services. For questions or comments related to this story, contact ruralhealth@nmu.edu.