Improving Rural Systems of Care for Time Critical Diagnoses: A Review of State Flex Program Activities

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 Medicare Rural Hospital Flexibility Program (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, researchers from the University of Southern Maine's Flex Monitoring Team 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).


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