Tiered EMS Systems Part 3
Implementing and Evaluating the System
The conclusion of a three-part series on matching EMS response capabilities with patient needs.
A tiered EMS pilot can produce an encouraging report: fewer ambulance transports, more community referrals, and additional availability for emergency calls. Those results deserve attention. They also leave an essential question unanswered.
What happened to the patients?
Did the receiving service see them? Did they understand the plan? Did anyone identify a deterioration while they were waiting? Was the necessary clinical capability available when a call turned out to be more serious than first reported?
Implementation has to answer those questions while keeping the service staffed and financially sustainable.
Part 1 distinguished response priority, clinical capability, and service function, using examples from different countries and regions. Part 2 examined how dispatch, field assessment, specialist support, transport, and receiving services connect. This final article considers how to introduce those arrangements, prepare the workforce, and determine whether the resulting care justifies expansion.
It also completes the connection with our Beyond the Emergency Department series. Community paramedicine, nurse navigation, telehealth, and alternative destinations can benefit from differentiated response capabilities when the system can carry a patient through to appropriate care.
The implementation framework below is my proposed approach for local planning. It is not a universal clinical protocol, funding model, or performance standard.
Define the benefit before launching the service
Begin with a problem that can be described and measured. A community might need earlier access to critical care expertise, better assessment of complex urgent needs, or a dependable connection between ambulance crews and an accepting community service.
Each problem calls for a different intervention. Adding a specialist response car may help with access to expertise. It will not create clinic capacity, answer a referral line, or provide suitable transport on its own.
Write a pilot charter that names the patient population, participating services, locations, operating hours, clinical decision authority, and intended benefit. Establish the emergency fallback, evaluation plan, and person or group responsible for deciding whether the service continues.
Include field clinicians, dispatch, medical leadership, nursing, educators, operations, receiving services, finance, and patient or community representatives. Where workforce arrangements may change, involve the relevant employee and volunteer representatives early.
Agree on what improvement would look like from the patient's perspective. An additional referral is valuable when it creates timely access to care. A shorter ambulance commitment is useful when the next service can meet the patient's needs and emergency cover remains adequate.
The pilot should test a defined care pathway with a defined purpose.
Prepare the workforce for the decisions it must make
Part 2 addressed role descriptions. Implementation turns those descriptions into demonstrated capability.
The US National EMS Scope of Practice Model distinguishes education, certification, licensure, and credentialing. It guides state systems and does not itself authorize a clinician to practice. A new service assignment must fit the applicable legal scope and local authorization. [1]
Build preparation around the work expected in the pilot. For a community referral role, this may include assessment, recognition of uncertainty, consultation, shared decision-making, documentation, receiving-service communication, and escalation. A critical care role will require a different preparation plan.
A lecture attendance record cannot establish how someone will manage an unanswered consultation or a changing patient condition. Use supervised practice, simulation, and observation of relevant decisions. Agree on who assesses competence, how authorization is recorded, and how staff receive feedback after real encounters.
London Ambulance Service describes additional education for its Advanced Paramedic Practitioners. Its Urgent Care practitioners also rotate through settings such as general practice, urgent care centres, and minor injury units. That is a service-specific example of connecting preparation with the clinical work; it is not an international qualification template. [2]
Train across organizational boundaries. Dispatch needs to know what the field team can provide. A receiving service needs to understand the referral information and acceptance process. A transport crew needs to know the care required during the journey.
Provide protected time for preparation and continuing review. Plan backfill, supervision, breaks, leave, and access to clinical advice. A pilot dependent on a few enthusiasts volunteering additional hours needs a workforce plan before it becomes a permanent service.
Competency assessment should include recognizing when the current response is insufficient and obtaining the additional help the patient needs.
Fund the entire care pathway
The business case should describe the cost of delivering the proposed service, including activity that does not end in ambulance transport.
Consider dispatch and secondary assessment, field care, consultation, transport, receiving-service capacity, follow-up, education, technology, data review, and clinical oversight. Separate startup costs from recurring costs. Explain who pays each cost and who may benefit from improved access or reduced utilization.
Additional ambulance availability is an operational benefit to measure. It is not automatically a cash saving. Staff, vehicles, and standby capacity may still be required, and a new referral service may add costs elsewhere in the pathway.
Payment arrangements also matter. In the United States, the CMS Emergency Triage, Treat, and Transport model tested payment for treatment in place and transport to alternative destinations for eligible Medicare fee-for-service patients. The model's performance period ran from January 1, 2021, through December 31, 2023. It should be discussed as a completed demonstration, rather than a current nationwide reimbursement entitlement. [3, 4]
Its final evaluation identified difficulties securing healthcare partners, EMS personnel challenges, patient reluctance, and technology or information-access problems. Payment flexibility alone did not resolve those implementation barriers. [4]
Other systems organize funding differently. King County describes regional EMS levy management alongside medical oversight, training, data analysis, and system planning. This illustrates funding for supporting system functions; it does not establish that the same financing arrangement is available elsewhere. [5]
For a proposed local service, confirm which organization will pay for assessment without transport, an unsuccessful referral attempt, necessary escalation, and the interval before the next service begins. Verify current payer and contract requirements before budgeting anticipated revenue.
Grants may help establish a pilot. The continuation plan still needs a credible source for recurring expenditure. Avoid building incentives that reward fewer ED transports regardless of clinical appropriateness or completed care.
Identify who funds each step before asking staff to deliver it.
Protect the patient throughout the transition
A patient should understand why a particular response or care pathway is being offered, what it can provide, and what happens next. Explain choices and limitations in accessible language, with interpreter or communication support when needed.
Clinical eligibility must follow local protocols and authorized decision-making. A dispatch category, professional title, or description of a call as low acuity cannot establish that an individual patient can safely avoid emergency evaluation.
NHS England's March 2026 urgent community care framework emphasizes shared decisions, support at home, escalation arrangements, and clarity about clinical responsibility after assessment, during handover, and throughout treatment. It expressly supports decision-making rather than serving as clinical policy. [6]
The practical safeguards follow the patient through the whole plan. Confirm an accepting service, an agreed next contact, suitable access or transport, interim responsibility, and a route for reassessment if the plan fails. Apply the local consent, capacity, safeguarding, and refusal requirements.
Consider the patient who cannot use video, has no reliable telephone, lives beyond the receiving service's coverage area, or needs help reaching an appointment. The pathway should provide a suitable alternative instead of making access depend on solving those problems alone.
Emergency assessment and escalation must remain available when indicated. Pressure on capacity or a pilot's utilization target should not determine the clinical decision.
Establish a way for patients, families, and staff to report concerns. Review failed connections as well as adverse events. An unanswered referral can reveal a service gap even when no harm has yet been identified.
Test in phases with explicit review points
A staged introduction gives teams an opportunity to identify problems before exposing a larger population to them. The stages should follow readiness and risk, rather than an arbitrary universal timetable.
I would use four phases.
Define and validate. Agree on governance, eligibility, roles, receiving arrangements, funding, data definitions, and emergency fallback. Establish baseline performance and check that the information needed for evaluation can be obtained.
Rehearse and observe. Test the pathway with dispatch, field staff, clinical advisers, and receiving services. Include unavailable specialists, unanswered referrals, connectivity loss, and deterioration. Where appropriate, review cases in shadow mode under existing care arrangements. Simulated and shadow cases must remain separate from actual treatment outcomes.
Run a limited live pilot. Introduce an approved pathway within clearly defined locations, hours, and staffing. Use close clinical oversight and timely case feedback. Record eligible patients who do not receive the new pathway, the reasons, and what care they receive instead.
Consider wider implementation. Review safety, completed care, workforce readiness, receiving capacity, costs, and data completeness before changing the population, hours, or geography. Test the changed conditions and continue surveillance.
The Institute for Healthcare Improvement's Model for Improvement supports small tests, learning from results, and testing under different operating conditions before wider implementation. The four phases above are an adaptation for this discussion, not an official EMS rollout standard. [7]
A daytime pilot cannot demonstrate that a referral pathway works overnight. A metropolitan service cannot establish rural feasibility without examining distance, backup, and receiving capacity. Evaluate the conditions proposed for the next stage.
Document the decision at each review point, including unresolved concerns and the resources needed to proceed.
Build trustworthy data before judging results
The system needs to distinguish several events: the pathway was considered, the patient was eligible, it was offered, the patient agreed, a referral was attempted, a service accepted, and care was completed. These events should not share one generic success code.
Agree on a data dictionary across dispatch, electronic patient care records, clinical consultation, and receiving services. Define each measure's population, numerator, denominator, exclusions, timestamps, reporting interval, and owner.
For referral completion, for example, state whether the denominator includes all attempted referrals or only accepted referrals. Report acceptance separately. Otherwise, a high completion percentage could conceal a substantial number of patients whose referrals were declined.
Retain reasons for non-use, refusal, failed acceptance, changes in the plan, and escalation. Check missing records and linkage failures. Where lawful and feasible, connect EMS information with receiving-service encounters, later urgent contacts, and relevant patient outcomes.
EMS.gov describes data collection, analysis, and sharing as important to improving EMS operations, clinician safety, and patient care. NEMSQA provides specified measures and recommends establishing a baseline before developing improvement interventions. Those resources can support measurement discipline; the proposed pathway measures here are not presented as NEMSQA-endorsed measures. [8, 9]
Validate electronic reports against representative case records. Include patients with failed referrals and incomplete follow-up, not just completed encounters. If some outcomes remain unknown, display that missingness alongside the results.
An unlinked record is an unknown outcome, not evidence that nothing adverse happened.
Measure benefits and possible tradeoffs together
A pilot needs measures that connect its intended benefit with safety and the work required to deliver care. The following is a proposed evaluation set for local adaptation, without universal targets or weights.
Evaluation domain | Examples to examine |
Access to required capability | Time from the relevant request or recognition point to necessary clinical capability; delays in consultation, specialist response, or transport. |
Safety and escalation | Adverse events, missed needs, delayed escalation, subsequent urgent contacts, ED attendance, hospital admission, and relevant clinical outcomes. |
Completed care | Referral acceptance, confirmed next-service contact, failed connections, and care completed within the agreed plan. |
Patient experience and equity | Understanding of the plan, preferences, accessibility, concerns, and differences by geography, language, disability, or other locally relevant factors. |
Operations and workforce | Ambulance commitment and availability, backup use, specialist workload, staffing reliability, competence, fatigue, and staff feedback. |
Cost and data confidence | Total pathway costs, financial sustainability, record completeness, outcome linkage, and follow-up coverage. |
Choose follow-up periods appropriate to the pathway and clinical risks, and define them before interpreting results. A return to emergency care may represent necessary escalation, progression of illness, or a failed original plan. Review the circumstances rather than labeling every later ED visit as a failure.
The ET3 final evaluation offers a useful caution. Treatment in place was associated with higher five-day follow-up ED use and hospitalization than its low-acuity ED comparison group. The report also describes limitations, including unmeasured differences between groups and too few alternative-destination interventions for statistical analysis. These findings warrant attention to selection and follow-up; they do not prove that every local treatment-in-place pathway causes harm. [4]
Pair each intended gain with a measure that could reveal an adverse tradeoff. If ambulance commitment falls, examine delays in reaching the next service and subsequent urgent calls. If specialist demand falls, examine missed needs and later requests for advanced care.
Display trends and case counts. IHI's run-chart guidance supports examining performance over time. A small denominator can produce unstable percentages, and a pilot with no observed serious harm cannot rule out rare adverse events. [10]
Compare like populations where possible and account for changes in staffing, receiving capacity, season, and case mix. A simple before-and-after improvement cannot establish how much of the change was caused by tiering alone.
Learn from international systems without copying their titles
The examples across this series show different ways to connect capability, coordination, and receiving care. Their useful features sit within local professional authority and service arrangements.
In London, specialist urgent care practice includes additional preparation and experience across clinical settings. In Lombardy, AREU describes nurse-based advanced response using authorized clinical algorithms under the indications of the emergency operations physician, alongside basic crews and physician-and-nurse advanced crews. The implementation lesson is to connect role preparation with the actual decisions and support available. These are regional service descriptions, not equivalent professional scopes. [2, 11]
Ambulance Victoria's 2024–25 annual report describes secondary triage linking patients with the Victorian Virtual Emergency Department. It also describes specialist services and follow-up calls within that virtual service. This demonstrates a connection to an available receiving service, rather than simply a decision not to send an ambulance. The annual report's service description does not isolate a causal effect of tiering. [12]
The transferable planning questions are practical. Who can make the decision? What preparation supports it? Which service can accept the patient? How is responsibility transferred? How is the whole pathway funded and evaluated?
Answer those questions locally before adopting a model described elsewhere.
Decide whether to expand revise or pause
Agree on decision rules before the live pilot begins. Clinical and operational leaders should know which concerns require urgent intervention, which require a revised process, and what evidence is needed for expansion.
Expand when the intended benefit is supported by sufficiently reliable evidence for the proposed next stage, safety findings have been reviewed, and staffing, receiving capacity, funding, and data arrangements can support the additional work. Preserve monitoring after expansion.
Revise when the evidence identifies a correctable gap, such as incomplete follow-up, frequent declined referrals, excessive specialist workload, or an operating period that does not match receiving-service availability. Specify the change, owner, and conditions for another test.
Pause a pathway when the service cannot provide essential assessment, support, accepted care, or a dependable emergency fallback. A serious safety concern requires prompt clinical review and risk mitigation. Define who can pause the pathway, how staff are notified, how patients already in it are protected, and what must be resolved before restarting.
Data that are too incomplete to assess outcomes should limit claims of success and support caution about expansion. Strong utilization results must not average away unresolved serious safety concerns.
These are proposed governance categories. The actual thresholds and responses need local agreement, adequate clinical oversight, and a process that protects patients while the decision is being made.
Completing the series
Part 1 asked how response capabilities can be matched to patient needs. Part 2 asked how the people and services involved can make that response work. Part 3 asks what an organization must demonstrate before making the model routine.
A useful tiered system makes appropriate expertise available, supports clinicians when the plan changes, and connects the patient with the next stage of care. Its value needs to be demonstrated through the care delivered, the experience of patients and staff, and the resources required to sustain it.
The patient should reach appropriate care without having to navigate the boundaries between our organizations alone.
Start the conversation
Which part of your proposed EMS pathway is least ready today: workforce preparation, receiving-service capacity, funding, or reliable follow-up data?
Choose one patient pathway and trace it with the teams responsible for each step. Bring a real process, identify the unresolved responsibility, and agree on one improvement to test safely.
Astera Global Solutions is based in the United States and works with EMS and healthcare organizations internationally on clinical quality, education, operational performance, and system development. If your organization is evaluating tiered response, nurse navigation, community paramedicine, telehealth, or alternative destinations, contact us to discuss the preparation and measurement your service needs.
Visit asteraglobalsolutions.net or email info@asteraglobalsolutions.net. Share this article with a colleague in clinical leadership, dispatch, education, operations, or community care, and tell us which connection your organization wants to strengthen.
References
Sources checked October 5, 2026. Service examples describe their cited jurisdictions. The implementation phases, evaluation domains, and decision categories are proposed planning tools for local adaptation.
1. National Association of State EMS Officials. (2019). National EMS Scope of Practice Model 2019. National Highway Traffic Safety Administration.
2. London Ambulance Service NHS Trust. (n.d.). Advanced Paramedic Practitioners.
3. Centers for Medicare & Medicaid Services. (n.d.). Emergency Triage, Treat, and Transport Model.
4. Centers for Medicare & Medicaid Services. (2025, January). Emergency Triage, Treat, and Transport Model Final Evaluation Report.
5. Public Health Seattle and King County. (n.d.). About the Emergency Medical Services system.
6. NHS England. (2026, March). Urgent community care clinical decision-making framework.
7. Institute for Healthcare Improvement. (n.d.). Model for Improvement.
8. National Highway Traffic Safety Administration, Office of EMS. (n.d.). Using EMS Data.
9. National EMS Quality Alliance. (n.d.). NEMSQA Measures.
10. Institute for Healthcare Improvement. (n.d.). Run Chart Tool.
11. Agenzia Regionale Emergenza Urgenza. (n.d.). FAQ 118.
12. Ambulance Victoria. (2025). Right care right patient right time. Annual Report 2024–25.
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