However you define it—and in recent years the U.S. government has done so 15 different ways1—a lot of America is rural. For purposes of ambulance service reimbursement, some parts are even super-rural.2 And beyond that, even more sparsely settled areas are tagged frontier, a common definition being a population density of six or fewer people per square mile.2
Then there’s Harney County, Ore. Located in the state’s southeastern “Empty Quarter,” it has roughly 7,300 people across 10,226 sprawling square miles3—an area bigger than six states. That squints down to a population density of 0.7, landing Harney among the 40 least densely populated counties in America.4 It meets other frontier criteria as well, including distance from and travel time to big cities: It’s 130 miles to Bend, 190 to Boise, 280 to Portland. Harney’s cows outnumber its people 14 to 1.5
Emergency medical services for the entire county come from Harney District Hospital (HDH) EMS. Based in the county seat of Burns (population 2,772), it’s a service that defies much of what you might expect for a jurisdiction that’s isolated, poor, and shrinking.
It’s an ALS service. It’s well-staffed. It’s financially viable. And its providers, facing an environment their urban counterparts often underestimate, are routinely challenged by distance and resources to perform to the boundaries of their scope and skills.
“We don’t need heroes—that’s not what we’re looking for in our community,” says Jeff Sceirine, EMT-P, the hospital’s EMS manager. “We’re looking for people who will help us in any way they can when things get rough. Because there’s no other help here—we’re it.”
The Only Defense
The EMS department at Harney District Hospital consists of Sceirine and four other full-timers, plus a roster of 15 “casuals” who are essentially paid volunteers. There are three paramedics. The call volume is about 1,000 a year, 96% of it in Burns and adjoining Hines. Around 800 come via 9-1-1; the rest are transfers.
Two or three personnel are on duty at any given time—two full-timers and a supplemental casual. Crews are on call for 24-hour shifts and respond from their homes. If a crew is occupied for a prolonged period doing a transfer or even just responding down to somewhere like Fields—the county’s southernmost town, some 110 miles away—it’s usually not hard to call another. Everyone’s close, everyone’s willing.
That there are so few, though—not only EMTs and paramedics, but physicians, nurses, and other health professionals in the county—necessitates a certain flexibility. Crews have to be intimate with all the skills and tools they might need to care for very sick patients on very long rides. They have to pitch in at the hospital if needed. They have to be OK as the only real line of defense, because often it’s not even feasible to call a helicopter.
“We’re even far for the air services,” says Sceirine. “If they get into the county to any certain distance, they have to go to the airport and fuel up to go back. And usually, because of the distances and flight times, we end up beating the flight crew back here with the patient.”
Some of those patients can be deep in the backcountry and badly hurt. Harney’s main industry is ranching, which produces some unique trauma—imagine a horse rolling over you. Out in the county, even locating victims can be a challenge. Closer to town, U.S. 20—long, straight, flat, and lightly used—produces some grisly high-speed crashes. But a lot of the county is simply empty; almost 75% of its land is federally owned. (Harney County was the site of the 2016 Malheur National Wildlife Refuge occupation.)
After the trauma, the call profile isn’t abnormal. Harney’s population skews older and isn’t wealthy; the median household income is just two-thirds the state average.
While ambulances come from Burns, the service invests in training and equipping volunteer first responders in the county’s farther-flung outposts. There are five in Drewsey, two in Fields, one each in Riley and Crane. They all have day jobs, though, so might also need some time to respond. They have AEDs but have only used them once or twice in nine years. Bystanders pitch in when someone’s hurt, and the local law can do CPR and defibrillate, but if you’re far from town and your problem is serious, your prognosis is grim.
“It sounds cold, but if you’re up on Steens [Mountain] and someone’s doing CPR on you, you’re not going to survive,” says Sceirine. “What’s scary for our guys is when they’re out with a patient 100 miles from the hospital and the patient arrests. Now you have 100 miles and some time to be working on this patient before you’re back to the hospital. So if you’re there when it happens, it’s terrible, but if you’re not there when it happens, the likelihood is even worse.”
No Place to Hide
Distances like that require providers with game. For someone with subpar skills, the frontier is no place to hide.
“In the city, EMS would drop a patient, sign out, and they were gone. You rarely saw the same person twice, and there was never much continuity,” says Sarah Laiosa, DO, the service’s medical director. “Here our guys come in, the patient will have a tube, an IO, all these things, either because of their comfort with those procedures or the distance they’ve come. I feel like I see a lot more appropriate interventions when people arrive.”
That requisite flexibility carries over to the hospital, where Laiosa also wears the hats of family medicine physician, medical director for hospice and clinic operations, public health medical officer, and medical examiner. She faces the formidable challenge of keeping a sharp edge on important skills providers may rarely use.
To that end the EMS team does plenty of work at the hospital, where a lot of the casuals have full-time jobs anyway, working as medical assistants, CNAs, even in security. If there’s a cardiac arrest in house, EMS personnel respond like everyone else. They do CPR, intubate, start IVs. Around a third of the IVs they start are there, “because we don’t get that opportunity in the field,” says Sceirine. Laiosa also ensures each member attends one live birth a year, in case one happens out in the county and they have to bring mother and baby back.
Having EMS personnel work for and in the hospital has an additional benefit to patients, who enjoy greater continuity of care and fewer of the handoffs that are so ripe for error.
The hospital has a 24-hour emergency department, but the doc and staff beyond nurses may need a few minutes to get there. They could be in the hospital, at its adjoining clinic, or home asleep. If it’s the latter, they have 20 minutes to arrive. Crews call ahead—cell and radio coverage permitting, which they don’t always—to start the clock. EMS uses leveling criteria in the field to give their docs an idea of what’s coming and guide resource preparation.
A helipad sits across the street. Acute patients can be flown to Boise or Bend, which have level 2 trauma centers, or to Portland for a level 1. Trauma accounts for fewer transfers than cardiac and dialysis, though. The nearest stroke center is in Bend; ischemic patients go on to Portland. Air support comes from Boise, Bend, or one of a handful of small Oregon towns (Redmond, Ontario, La Grande).
There’s no community paramedicine program, because it would be redundant. The principles already infuse how the system operates: Hospice and a clinic are integrated. Patients have easy access to physicians and midlevels. Docs do home visits; ambulance crews might deliver meds. There are community health workers. A special reimbursement plan for rural hospitals mitigates the need to transport everyone—in fact, EMS crews try not to.
“Our goal is to maintain a high nontransport rate,” says Sceirine. “We’ll do a full evaluation in the field and decide if the patient needs to go to the ER or the clinic. If they just need the clinic, we’ll call to get them in. If they need transport, we’ll call a taxi.” The hospital may even pay for the taxi if a patient can’t.
Crews may call a patient’s primary care physician directly from the scene—the town is small enough to know them all. “If they can call the PCP,” says Laiosa, “the PCP can tell us, ‘Well, I was at his house yesterday, and he didn’t look like that—bring him in.’”
Comfortable Being Uncomfortable
This all requires a certain type of provider. And while finding them in a place like Burns isn’t always easy, hiring the right ones has led to good retention. The service is currently trying to hire a paramedic, but it’s the first time in eight years.
EMTs are homegrown, taught by HDH paramedics through a local community college outreach program.
“It’s hard to find really good fits for this community because as a paramedic you have to be comfortable with so many things,” says Laiosa. “Mostly you have to be comfortable with being uncomfortable. For example, these guys ventilate patients—they have to be comfortable for three hours with a patient on a vent. It’s hard for us to hire city paramedics because they don’t always have that skill set.”
The softer skills are important too. Life in a small town isn’t for everyone. You have to value community. You’ll know the neighbors you’re helping. In Burns any doc will take your call, and a plea for extra hands will likely bring multiple sets.
“I’ve worked in systems that were much bigger, and there’s a real connection being in a small town,” says Sceirine. “There’s an attachment that makes it even more important for us to make sure people get what they need. We have to get Gladys off the floor again, and it’s the fourth time this week? Well, that’s all Gladys has—there’s nothing else here for her! So we really buy into that.”
Balancing the Books
Harney District Hospital took over EMS duties from the Burns Fire Department in 2000. At the time the service was struggling. Aligning with the hospital was a financial lifeline.
As a critical access hospital—a federal designation designed to reduce facilities’ financial vulnerability and keep essential services in rural communities—HDH is eligible for cost-based reimbursement from Medicare. That compensates it at 101% of all allowable costs. Making EMS part of the hospital got its costs covered under the same mechanism.
The other main revenue source is property taxes, which yield about $1 million a year. “Without that property tax base,” says Catherine White, the hospital’s CFO since 2009, “we probably wouldn’t have a hospital here.”
Billed rates are on the high side, as there aren’t a lot of other sources of income, but a lot is written off. As a small hospital HDH has negotiated solid contracts with private payers, though they’re not a big chunk of the income profile.
“The effect on their budgets is minimal for our hospital and the size of our community, and I’m pretty good at playing the poor card,” says White with a smile. “‘We can’t take less than that! We can’t function without it!’ The property tax base keeps us on the positive side, but if we weren’t collecting what we could from those commercial payers, we’d definitely struggle.”
Around 20%–30% of revenue comes from Medicaid—its expansion in Oregon has made a big difference, White says. And the hospital has added numerous capabilities to help keep local dollars local: It bought the clinic, launched a pain-management program, orthopedic and dermatology services, an infusion clinic. It’s hired more providers. It’s looking now for an occupational therapist and licensed clinical social worker (LCSW).
If there’s a financial threat, it’s losing the critical access hospital (CAH) designation. The CAH standard requires no more than 25 acute-care inpatient beds and at least 35 miles to the next hospital. Not all hospitals that meet that definition struggle. Pinching the benefits down could do far more damage to a place like HDH than it might to others.
“There’s always opposition to cost-based reimbursement at the national level,” says White. “When you lump us in with some of those other places, a lot of those hospitals are at capacity because they draw from larger communities, but they’re designated critical access because they meet that definition. We’re very different from them. We average five patients a day on the inpatient side, and EMS averages two runs a day. If they decide at the national level to make changes to that whole system, it could affect us greatly.”
Closeness and Collegiality
Adversity brings people together. And while living in a pleasant little town on a remote western frontier isn’t exactly hardship, in Burns it has fostered, in its EMS service, small hospital, and compact local healthcare system, that sense of closeness and collegiality to which everyone aspires.
“In a small service like this, we’re dependent on each other and see each other all the time,” says Sceirine. “We might go to each other’s houses for dinner or go goof around together on a day off. If we don’t get along, we won’t be able to function. And here everybody really gets along.”
What’s even more important, though, is the quality of the local caregiving chops. The frontier is unforgiving. Don’t take its EMTs and paramedics as anything less than you’d find in the metro world. They might be more.
“As a nurse, I am just floored at the knowledge they have, the skills they possess, and their ability to take a terrible situation and remain calm and provide care,” says Mary Schimmelpfennig, RN, a nurse at the hospital since 2012. “They have become resources for absolutely everyone and provide a sense of confidence and comfort when they walk into the ER.
“I think a lot of times, when we’re transferring patients or giving a report to people in Bend or Boise or Portland, people might assume we’re from the middle of nowhere and don’t really know what we’re doing. I wish they could realize there’s some very true and real talent and professionalism out here, and some really good medical care being provided. No, we can’t send somebody to a cath lab, but we can dang sure get them ready to go and stabilize them until they can get there. Given our circumstances and resources, we really are providing some pretty darn good care.”
What do rural, super-rural, and frontier actually mean in healthcare?
Rural—The federal government has at least 15 definitions of rural, and in 2015 the Washington Post rounded them all up.1 Most came from the Department of Agriculture; only one came from the healthcare realm: DHHS’ Office of Rural Health Policy defines it as any area with a Rural-Urban Commuting Area code between 4 and 10.
RUCA codes classify U.S. census tracts using measures of population density, urbanization, and daily commuting. A 1–10 scale delineates metropolitan, micropolitan, small town, and rural areas based on the size and direction of primary commuting flows.
Super-Rural—The Centers for Medicare and Medicaid Services designates areas as super-rural for enhanced reimbursement of ambulance services. Super-rural areas are the bottom quarter of rural zip codes by population density.
Frontier—There’s no single definition of frontier, but a common threshold is a population density of six or fewer people per square mile. The National Rural Health Association also cites distance from and travel time to population centers and specific services, functional association with other places, availability of paved roads, and seasonal changes in access to services.