Minding the Gap: Why Stratford EMS Added Interfacility Transport
By Michael A. Loiz, Director of EMS, Stratford EMS
On October 28, Shell Piercy, Chief Paramedic Officer for Australia's Northern Territory, posted a reflection from the Bali 2026 Emergency Care Conference called Beyond the Ambulance: Rethinking Emergency Care Through a Systems Lens. Her presentation, Mind the Gap: Translating the Transition of Care, came down to three short lines on a slide:
One patient. Multiple clocks. Unclear clinical ownership.
One sentence from her article has stuck with me: "patient flow is a whole-of-system challenge." Another follows close behind, drawn from Bill Kinch's session at the same conference: "Not every patient requires the same response, the same destination, or the same care pathway."
I read those lines from the other side of the world, and they described almost exactly the conversation we've been having in Stratford for the past year. They're also the clearest way I've found to explain why Stratford EMS, a municipal third-service ALS agency that has done only 9-1-1 for its entire history, decided to add interfacility transport (IFT) as a service line.
I want to be honest about how we got here, because this wasn't a growth strategy dreamed up in a good year. It was a decision we had to make.
Stratford EMS has always been a 9-1-1-only service. We built our identity around doing that one job well, and by the measures our profession uses, we do. We meet our response, clinical and operational KPIs. In Fiscal Year 2026 we handled 8,231 calls.
Performance alone doesn't fund a system, though.
Like EMS agencies all over the country, we're operating in a healthcare funding environment that keeps getting tighter. When coverage shrinks and access to everyday care gets harder, people don't stop getting sick. They wait longer, their conditions get worse, and more of them turn to the one part of the healthcare system that always answers: 9-1-1. EMS becomes the safety net for the safety net.
The hard part is that the same funding pressures that reduce people's access to care also hit the reimbursement that keeps EMS running. Demand rises while the dollars behind each response shrink. Those two trends can't keep pulling in opposite directions without something giving way.
There's a part of EMS funding most residents never see.
Stratford EMS is largely self-funded. Most of what it costs to run the service comes from what we bill for the care we provide, not from the tax levy. That's something our team is proud of, but it also exposes a gap in how communities think about public safety.
When a police or fire budget falls short, the answer is generally to fund the gap, because everyone accepts that those services have to be there. EMS is usually held to a different standard. We're expected to make our own way, and our options for doing that are few: commercial insurance, Medicare and Medicaid.
Each of those has limits. Commercial insurers manage their costs by limiting what they pay, and EMS claims are no exception. Medicare and Medicaid reimbursement has long paid less than the cost of providing the service, and it moves with every budget debate in Washington and in state capitals. That's been true no matter which party holds the majority. When those programs are cut, the conversation rarely gets around to a simple question: where is EMS supposed to get its revenue?
A common answer is "just recruit more volunteers." I have enormous respect for volunteers. They built EMS in this country, and many still serve their communities with extraordinary dedication. Stratford EMS has its own proud volunteer history. But in an economy where many families need two incomes just to get by, fewer people have the time to give. Volunteerism is something to treasure. It isn't a funding plan.
So EMS agencies do what they have to. We hire more people to meet our communities' growing demand, even as the funding sources we depend on keep getting squeezed. More demand, more staff, less reimbursement per call. Left alone, that cycle wears systems down until something breaks, and when EMS breaks, it's patients who feel it first.
Some suggest that moving EMS under a different structure will solve the problem. Every model has strengths, and I know outstanding EMS systems that operate as part of fire departments, hospitals and other organizations. But changing who EMS reports to doesn't change what EMS costs or what it gets paid. The funding gap is still there; it just moves into someone else's budget, where it's harder for the public to see. I'd rather keep that gap visible, be transparent with our community about it, and work on real solutions.
I don't say any of this to make a political point or to criticize any other agency or model. Every EMS leader I know, in every kind of system and community, is dealing with the same math. It's simply the environment we all work in, and pretending otherwise doesn't protect anyone.
So we had a choice to make, and in reality it wasn't much of a choice. We could keep doing exactly what we'd always done and hope the numbers worked out, or we could think differently about what a municipal EMS agency can be. We chose the second.
Piercy makes a point I think American EMS needs to hear. What Australia calls ambulance ramping, and what we usually call wall time or offload delay, is more accurately a transition-of-care delay. As she puts it, these challenges are "too often" framed as ambulance problems or emergency department problems. In reality, rising ambulance demand, ED crowding, access block and delayed handovers are "interconnected indicators of a health system operating under significant pressure."
That changed how I looked at our own work.
For decades our model was simple. Someone calls 9-1-1, we respond, we treat, we transport, we hand off at the emergency department, we clear. Our performance measures and our identity both lived inside that window.
That window is real and it matters. But the patient doesn't live inside it.
Every one of our calls started a clock we could see: response time, on-scene time, transport time, time to hand off. What we couldn't see, and honestly didn't consider ours, were the other clocks running on the same patient:
When those clocks run long, the cost doesn't stay where it started. A bed that can't be emptied is a bed the ED can't fill. An ED that can't move patients up is an ED where our crews stand at the wall. The wall time we measure on our side is often just the visible end of a delay that started somewhere upstream, in a discharge that couldn't happen or a transfer that couldn't move.
From the patient's point of view, as Piercy writes, dispatch centers, ambulance services, emergency departments, hospitals, primary care, urgent care and community providers "are not separate entities." They're "components of a single healthcare journey." We'd been measuring our piece of that journey very well. We hadn't been asking much about the rest of it.
That's when it clicked for us. The new service line that could help keep us sustainable was the same one that could help close some of those gaps.
Bill Kinch's session, The Waiting Room on Wheels: Managing Non-Emergency Patients, gets at the other half of this. For years the default answer for almost any patient who needed to move was an emergency ambulance, whether or not the need was an emergency. That's a mismatch, and it's hard on everyone: the patient, the hospital and the 9-1-1 system.
Not every patient needs the same response, destination or care pathway. A scheduled discharge home, a transfer to a higher level of care, a dialysis appointment and a cardiac arrest are four very different needs. A well-designed system matches each one to the right resource at the right time.
For us, IFT is part of building that match. It gives scheduled and non-emergency transport needs a planned, appropriate pathway of their own, so they aren't waiting on an emergency system built for something else, and so the emergency system stays available for emergencies.
What finally moved this decision was realizing that IFT wasn't just a revenue answer. It addressed several problems at once.
IFT brings in new, scheduled, billable work that uses the clinical infrastructure our community has already invested in. It's part of a broader long-range plan that includes ordinance updates, service expansion, diversified revenue and expanded career opportunities, so we aren't relying on emergency billing alone to sustain the service.
Every hour a medically ready patient waits in a hospital bed for a ride affects the ED, and that affects our 9-1-1 crews. Helping move patients through the system on time isn't a side business. It's upstream protection of emergency response.
"Unclear clinical ownership" is the line from Piercy's slide that stayed with me most. When a patient is handed from facility to transport to destination, every handoff is a chance for information, medications or expectations to get lost. We're building our IFT intake so that a sending clinician's report, the right level of care and clear escalation criteria are part of the booking itself, not something figured out later in the hallway.
Some of the people most affected by tightening healthcare funding are the same people who struggle most to get a timely, dignified ride to the care they need: older residents, people with disabilities, and families without the resources to manage it alone. Piercy reminds us that patient-centered care starts with dignity and with health systems that are safe, respectful and accessible to every member of the community. A local, publicly accountable transport option is one way we can deliver on that.
Scheduled transport work creates real career pathways: more full-time positions, predictable shifts, new clinical exposure and room to grow supervisors and educators. A system that wants to keep its workforce has to give that workforce somewhere to go.
I don't want to make this sound simple, because it isn't.
Interfacility transport is a different business from 9-1-1. It has its own operational demands, documentation requirements, payer rules and relationships with facilities. Agencies that do it well have spent years learning how, and I have a lot of respect for them.
Expectations matter just as much. Our community has always known Stratford EMS as its emergency ambulance service, and residents rightly expect that when they call 9-1-1, we'll be there. Any change to how we use our resources has to earn and keep that trust. Our staff have expectations too. Many of them chose this agency because it's a 9-1-1 service, and asking them to take on scheduled transport work raises fair questions about workload, identity and what kind of organization we're becoming.
Those concerns could easily have stopped this effort before it started. Moving forward took some courage. We had to listen to those concerns, take them seriously and design the program around them instead of past them. In the end we decided the risks of standing still were greater than the risks of change, and that we could do this in a way that stays true to who we are.
Piercy makes another point every EMS leader should take seriously: "innovation alone is not enough." New models of care have to be supported by "strong clinical governance, robust evidence, clear accountability and ongoing evaluation," and the real challenge is "finding the right balance between innovation and assurance."
That balance shaped how we built this program.
The goal isn't just efficiency. It's better outcomes for patients, with safety, quality and equity of access protected along the way.
Piercy also notes that effective health systems "cannot be designed through a one-size-fits-all approach." They have to reflect the realities of the communities they serve. That's true for us too.
There are many good models for IFT across this country, and many agencies run it far larger and more complex than we ever plan to. I'm not suggesting our way is better. It's just the way that fits our community, our size and our mission.
For us, that comes down to a few commitments:
Piercy describes secondary triage, alternative care pathways, community paramedicine, urgent care integration and transition-of-care reform as "critical components of a sustainable healthcare system." IFT is our first step in that direction, not our last.
In parallel, Stratford EMS is working with Emergency Management, the Health Department, Senior Services and Stratford VNA to assess community health gaps before choosing a Mobile Integrated Healthcare pilot for 2027. Our early analysis of repeat 9-1-1 use suggests that a relatively small group of residents accounts for a meaningful share of our encounters. Many of them move back and forth between home, hospital and facility, which makes them exactly the patients IFT serves.
That's the whole-of-system idea in practice. 9-1-1, interfacility transport and community paramedicine aren't three separate businesses. They're three points of contact with the same people, and when one accountable agency connects them, the gaps get smaller.
None of this works in isolation. It depends on partnership with our hospitals, our medical directors, our dispatch center, our Town departments and the community providers who care for the same patients we do. Designing around what patients actually need, rather than around how our organizations have always been structured, is the real work.
Every EMS system is facing some version of this pressure, and every community will find its own answer. Some agencies have been doing IFT well for decades and have plenty to teach the rest of us. Others will find different paths that make more sense for them. I'm not suggesting IFT is right for everyone. It takes honest capacity planning, real clinical governance, billing discipline and the willingness to say no when the emergency system needs you.
But I would encourage every leader to ask the questions we asked:
Where does our responsibility to the patient actually end? Who is managing the clock after we leave? Are we sending the right response to the right patient? And are we willing to change, carefully and honestly, so we can keep serving our community well?
For Stratford, the answer was to mind the gap ourselves, within our means and true to our mission.
I'm grateful to Shell Piercy and Bill Kinch for sharing these ideas and for showing that the challenges we face in a Connecticut town look a lot like the ones being worked on in the Northern Territory and around the world. The future of emergency care, as Piercy writes, "will not be defined by any single discipline." It will be built through collaboration.
In our 50th year, that feels like the right way to honor the people who built this service: not by protecting the boundaries they drew, but by doing what they always did, finding a way to take care of our community when it needed us.
Michael A. Loiz is Director of EMS for Stratford EMS in Stratford, Connecticut, and owner of The Public Safety Consulting Group. He serves as NAEMT Connecticut Advocacy Coordinator and chairs the Connecticut EMS Advisory Board Legislative Committee.
Inspired by Shell Piercy's Beyond the Ambulance: Rethinking Emergency Care Through a Systems Lens and Bill Kinch's presentation, The Waiting Room on Wheels: Managing Non-Emergency Patients, at the Bali 2026 Emergency Care Conference.
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