A 911 call from a rural school reported that a teenage boy with diabetes was experiencing dangerously high blood sugar and needed help. EMS responded, assessed him, provided appropriate care, and reinforced the guidance he had heard from hospital staff and physicians: monitor his blood sugar, take his medications as directed, and choose foods that would help keep his glucose within a healthy range. The call appeared routine until it became the first of seven.

After the seventh emergency response, the EMS providers went to the student’s home. There, they discovered what could not be seen in the classroom, ambulance, clinic, or emergency department. His family relied on a local food bank, and many of the foods available to them were inexpensive, shelf-stable products high in simple carbohydrates. The family understood the dietary recommendations, but they did not have consistent access to the foods needed to follow the guidance.

The recurring emergency was not caused by a lack of education, effort, or concern. It reflected a gap between the care recommended from health care professionals and the resources available in the student’s home. Each organization involved had addressed the immediate clinical need, but the underlying health barrier remained invisible until someone saw where and how the student lived.

This example demonstrates both the reach and the limitations of traditional emergency care. EMS clinicians enter homes and communities, placing them in a unique position to identify food insecurity, transportation problems, medication barriers, unsafe living conditions, behavioral health needs, and other factors that may repeatedly produce a crisis. However, these insights are only valuable if a system is built to address them. Mobile Integrated Health (MIH) and community paramedicine create a structure for turning those observations from EMS clinicians into coordinated action. EMS does not replace primary care, schools, public health, hospitals, food-assistance programs, or social services. Its role is to connect these services around a plan that aligns clinical recommendations with the realities of a patient’s circumstances.

The lesson extends beyond diabetes. For a patient experiencing a serious injury, overdose, behavioral health crisis, or other emergency, geography and local circumstances can shape every part of the response. Rural residents often travel farther for emergency and specialty services, while local EMS agencies and hospitals must operate with smaller workforces and fewer nearby resources.1,2 These conditions do not make high-quality care impossible, but they require a coordinated system designed around distance, local capability, and dependable connections to regional and statewide resources.

Rural emergency care is often discussed as separate parts: ambulance response, hospital care, trauma designation, behavioral health, or patient transfer. Patients experience it as one continuum, beginning before the 911 call, continuing through assessment, treatment, transport, and transfer, and extending into recovery. North Carolina can strengthen this continuum by building capacity at several points: Mobile Integrated Health (MIH) can bring care into homes and communities; primary 911 EMS agencies can provide immediate assessment and stabilization; level III trauma centers can provide organized trauma care closer to rural patients; and level I and II trauma centers can provide advanced specialty care when needed.

EMS as Rural Health Infrastructure

In many rural communities, EMS is one of the few health care resources available around the clock, including nights, holidays, and during severe storms.1 EMS clinicians enter patients’ homes, encounter people during periods of significant vulnerability, and see medical, behavioral, environmental, and social risks that may not be visible elsewhere in the health system. They also respond to patients whose needs cannot be resolved through a single emergency department visit.

This reach makes EMS a critical component of rural health infrastructure, in a role that extends beyond emergency response. While core 911 readiness remains the foundation and first operational responsibility, expanding EMS capabilities allows communities to leverage EMS clinicians’ skills and trusted local presence to address gaps that repeatedly produce crises.

North Carolina’s Investment in Mobile Integrated Health

North Carolina has created a significant opportunity to test this approach. In June 2026, the North Carolina Department of Health and Human Services announced $10 million in funding for 39 local EMS agencies through the North Carolina Rural Health Transformation Program.3 Administered through the North Carolina Office of Emergency Medical Services, the funding will support EMS-led MIH and community paramedicine programs, strengthen the EMS workforce, and expand rural access to mental health and substance use disorder services.3 The funding opportunity is part of a five-year initiative focused on behavioral health crisis response, substance use disorder treatment access, and reducing emergency department use associated with mental health crises and opioid overdoses.4

The investment is important because it supports primary 911 EMS agencies that already have community reach and established relationships, with many EMS providers being long-time members of the community themselves. Funded activities may include providing medication for opioid use disorder, conducting rapid follow-up after an overdose, and connecting people to treatment and recovery services.3 Locally designed programs can also help patients navigate behavioral health services and coordinate with hospitals, public health, primary care, peer support, and community organizations.

MIH is most effective when it strengthens connections among existing services rather than attempting to replace them. A community paramedic may provide an immediate clinical intervention, but long-term recovery often depends on medication access, treatment availability, peer support, transportation, housing, and follow-up care. Formal referral pathways and shared accountability across partner organizations are therefore as important as the care delivered during the home visit. Through these partnerships, community paramedicine programs can also connect patients with food, housing, transportation, and other services that shape health outcomes.5

This investment should be viewed as both an expansion opportunity and a learning opportunity. North Carolina can use the initiative to identify which interventions work across different rural settings, how programs affect patient outcomes and 911 operations, and what financing arrangements are needed after grant funding ends. Historically EMS payment structures have remained oriented toward transportation to a hospital emergency department.6 This creates a financial mismatch for MIH programs, whose value may come from treating patients in place, preventing repeat emergencies, supporting recovery, or connecting patients to more appropriate services. Long-term sustainability for MIH will require Centers for Medicare and Medicaid Services (CMS), commercial payors, health systems, and other partners to develop payment approaches that recognize these patient outcomes and their cost savings, not just the ambulance transport.

Level III Trauma Centers as Regional Anchors

MIH concentrates on the early stages of the continuum by preventing recurrent health crises and improving care continuity before an emergency escalates. However, not every emergency can be prevented. When a serious injury occurs, level III trauma centers provide another layer of local and regional capability. North Carolina defines a level III trauma center as a hospital that provides “…prompt assessment, resuscitation, emergency operations, and stabilization and arranges transfer to a level I or II center when needed.”7

For rural communities, the value of a level III trauma center is not measured only by the patients it transfers. These centers can provide definitive care for patients with mild to moderate injuries, allowing appropriate patients to remain closer to home while maintaining processes for rapid evaluation, initial management, and transfer when a patient’s needs exceed local resources.8 Their organized trauma programs also support consistent activation practices, performance improvement, clinical education, injury prevention, and coordination with surrounding EMS agencies and receiving centers.

Trauma center designation provides benefits that extend beyond injured patients. The specialized resources, multidisciplinary teams, and around-the-clock capabilities required of a trauma center may enhance the hospital’s ability to care for a wider range of ill and injured patients.7 These capabilities are especially important in our rural communities, where access to specialized care may be limited and trauma centers often serve as a critical resource for patients experiencing both traumatic injuries and other life-threatening medical emergencies.

Level III trauma centers can therefore serve as regional anchors within a tiered trauma system.2 According to Hernandez and colleagues, “Designation of rural hospitals as level III trauma centers was associated with a 32% reduction in mortality…”2 They help rural EMS agencies make destination decisions, provide an appropriate point of initial hospital care, and create stronger transfer relationships with level I and II trauma centers. They can also help prevent unnecessary transfers when a patient can safely receive care locally.2 This preserves higher level resources and reduces the burden on patients and families.

Designation alone, however, does not create sustainable capability. Hospitals must maintain clinical coverage, training, quality-improvement processes, equipment, and reliable transfer plans. Lower patient volumes, workforce limitations, and the financial cost of continuous readiness can make these requirements difficult to sustain. Decisions about developing or supporting level III trauma centers should therefore be based on geography, community need, existing hospital capability, EMS transport patterns, and regional trauma-system planning.2

Measuring the Whole Patient Journey

A connected rural system also requires connected information. Traditional measures such as ambulance response time or the outcome of a single hospital encounter reveal only part of the patient’s health care experience. North Carolina should continue building measures that examine the full journey: time to the most appropriate clinical setting, trauma triage and destination decisions, transfer time, outcomes for patients treated locally, successful connection to behavioral health or substance use treatment, repeat crises, and access to follow-up services. Performance measures must also account for the realities of rural care delivery. Distance, staffing models, hospital capability, and available community services influence what an EMS agency or hospital can achieve. Data should serve as a tool for identifying gaps, guiding investment, and supporting system improvement. Its purpose should be to drive progress, not compare communities operating under different constraints.

From Time-Limited Funding to Lasting Capacity

North Carolina’s Rural Health Transformation Program is backed by a broader federal investment intended to improve rural access, quality, workforce, technology, and care delivery. The challenge is to convert time-limited funding into durable local capacity.9

For MIH, sustainability requires demonstrating impact through meaningful measures, including patient outcomes, treatment engagement, repeat overdoses or crises, emergency department utilization, workforce effects, and 911 availability. It also means developing durable payment models involving Medicare and Medicaid, private insurers, health systems, and community partners.6 For trauma care, sustainability requires continued investment in workforce, readiness, performance improvement, regional coordination, and transfer capability.

Three principles should guide the work. First, rural strategies should strengthen rather than fragment existing local systems. Second, programs should be designed in collaboration with rural EMS agencies, hospitals, clinicians, patients, and community partners, not merely delivered to them. Third, investments should reward collaboration and measurable patient benefit rather than the creation of isolated programs.

Conclusion

It took several emergency responses before anyone recognized what kept the teenage student with diabetes sick. A strong and connected health system is designed to recognize the barriers that drive recurrent health crises sooner. It must also ensure that patients receive appropriate care when crises do occur. Meeting both aims in rural communities requires coordinated capacity across the continuum of care.

North Carolina’s investment in EMS-led MIH and community paramedicine can expand access to behavioral health, substance use services, and care coordination into rural communities. Strong level III trauma centers can provide organized injury care closer to home while connecting patients to higher-level specialty care when necessary.

Together, these strategies illustrate what rural health transformation can achieve: a connected continuum that extends from prevention and early intervention through emergency response, definitive treatment, and recovery. Sustainable funding, workforce support, shared data, and durable regional partnerships will determine whether these investments produce lasting improvements for rural communities.

Financial Support

The author has no financial support to disclose.

Declaration of Interests

The author has no conflicts of interest to disclose.

Correspondence

Address correspondence to Kimberly Clement, 1915 Health Services Way, Raleigh, NC 27607 (Kimberly.Clement@dhhs.nc.gov).