Improving Rural Systems of Care for Time Critical Diagnoses (Briefing Paper #41)

Document Type

Briefing Paper

Publication Date



rural, Flex Program, EMS, Time Critical Diagnoses, Critical Access Hospitals, MRHRC


This paper examines the efforts of state Flex programs to support the development of Emergency Medical Services (EMS) time critical diagnoses (TCD) systems of care, which includes stroke, ST-Elevation Myocardial Infarction (STEMI), and trauma. The severity of these conditions necessitate a coordinated regionalized approach to transportation, diagnosis, and treatment to meet recommended treatment windows (e.g., the golden hour in trauma or a door to balloon time of 90 minutes for patients with STEMI) to maximize patient outcomes. These efforts to support the engagement of rural EMS agencies in TCD systems of care are an optional but important area of Flex Program activity under Program Area 3 - Population Health Management and Emergency Medical Services Integration. Through a review of state Flex grants and progress reports as well as interviews with state Flex coordinators and EMS stakeholders, we examined state Flex program initiatives to improve TCD system capacity and integrate EMS into local/regional systems of care, particularly those served by Critical Access Hospital (CAHs).


  • Collaboration between state Flex programs and the time critical diagnoses (TCD) stakeholders encourages a consistent focus on rural TCD issues and improves system-level communication.
  • Flex funds can be used to leverage other state EMS resources to improve rural TCD performance and undertake projects for which there may be no other source of funding.
  • Data collection at the local, regional, state, and program level remains challenging, impacting the ability to improve EMS TCD system performance and monitor Flex Program impact.
  • Training is a significant area of state Flex program TCD activity, but states struggle to directly connect participation in the trainings to changes in local EMS operations and/or performance.
  • State Flex programs must move beyond training and partnership activities to engage EMS, CAHs, and other stakeholders in making local/regional system changes to improve TCD services.


The Medicare Rural Hospital Flexibility Program (Flex Program) was created by Congress in 1997, allowing small hospitals to be certified as Critical Access Hospitals (CAHs) and offering grants to States to help implement initiatives to strengthen the rural health care infrastructure. The Flex Program is administered by the Federal Office of Rural Health Policy within the Health Resources Service Administration, US Department of Health and Human Services. The Flex Monitoring Team, which conducts research and evaluation on Flex Program activities, is a consortium of the Rural Health Research Centers at the University of Southern Maine, University of North Carolina-Chapel Hill, and the University of Minnesota. For more information, please visit http://www.flexmonitoring.org

bp-41-improving-rural-systems-of-care-for-time-critical-diagnoses.pdf (401 kB)
Improving Rural Systems of Care for Time Critical Diagnoses (Briefing Paper #41)