The heat rolled out of the house as soon as the door opened. A developing storm had cooled the air outside, but inside Elizabeth Fitzgerald’s small brick home, the temperature was stifling.
“Why is it so hot in here?” Keith Carroll asked as he stepped through the front door.
Carroll leads the community paramedicine program at the Danville Life Saving Crew. He has already worked with the city of Danville and the Southern Area Agency on Aging to make several repairs to Fitzgerald’s house.
This time, the air conditioning had stopped working. Carroll jotted a note on his hand and said he would check around town for someone who could help Fitzgerald fix the problem.
Fitzgerald’s hospital bed took up nearly all the space in the living room. Most of the remaining square footage was filled with furniture: a powerlift recliner, a rollator walker with the seat doubling as a nightstand and, on the far side of the living room, a couch made up as a bed.
Fitzgerald, 79, lay in the middle of the hospital bed with a landline telephone tucked under her arm.
“I still don’t have a cellphone,” she said.
“But she puts that one to work,” Carroll added, pointing at the phone.
The two met about five years ago when Fitzgerald, who uses a wheelchair, needed more help around the house. She was calling 911 to help with basic needs. She also has poorly managed diabetes and had lost consciousness more than once when her glucose skyrocketed, Carroll said.
Now, she’s a regular client on Carroll’s community paramedicine route — a free service that aims to address gaps in healthcare and other nonmedical factors that influence health, such as community, living conditions, access to food or affordable housing.
He’s helped Fitzgerald arrange doctor’s appointments and the transportation she needs to get there. He picks up her medications for her. And when her water heater broke, Carroll worked with local organizations to get a new one.
He stops at her house three or four times a month. Her calls to 911 have significantly decreased to about once a year, when her blood sugar rises to dangerous levels, Carroll said.
About this story
Volunteer fire departments across our region are the first line of defense during emergencies for many communities, but they continue to grapple with declining volunteerism, inadequate resources and funding, and the changing nature of their work.
Cardinal News is amplifying potential solutions to these problems in a monthslong project; check out our project page here to follow along.
In these programs, community paramedics identify people who frequently use the 911 system, often for recurring or non life-threatening problems. With a patient’s permission, the paramedics assess the underlying issues and connect them with the services they need.
Programs like Danville’s can help fire and EMS agencies reduce repeat 911 calls by addressing the problems that send the same patients back to the emergency system again and again. That can also ease some of the pressure on ambulance crews — a potential benefit for volunteer agencies that already struggle to recruit and retain enough people to cover emergency calls.
A 2023 survey by the National Association of Emergency Medical Technicians found that at least 40 states had launched community paramedicine programs or similar mobile programs. In Virginia, these programs are managed independently at local EMS and health system levels, meaning there’s no official, centralized public total of the number of community paramedicine programs.
Launching a community paramedicine program requires resources that many volunteer fire and EMS agencies do not have. Agencies must find people with the time and training to build the program, identify community needs, develop partnerships and secure funding to sustain the work.
And while community paramedicine programs can reduce unnecessary use of emergency services, they do not fit neatly into the traditional EMS reimbursement model. Medicare, which is regulated by the federal government, does not reimburse community paramedicine services.
For agencies already operating on tight budgets — particularly volunteer organizations struggling simply to maintain emergency coverage — finding the money and staffing to add another service can be a significant hurdle.
But some localities have made it work with the support from local governments or local funders.
First responder burnout is fueled, in part, by the sheer volume of calls
In Pulaski County, three ambulances serve 330 square miles. Yet only about 15% of the calls they respond to are true emergencies, said Mike Garnett, Pulaski’s assistant chief of EMS.
“That’s the part of the job they don’t tell you about,” Garnett said. “People are calling us to help them get out of bed in the morning so they can start their day.”
There are people who will call multiple times a week — even twice a day sometimes, Garnett said.
Last year, Pulaski County EMS recorded 5,420 patient encounters involving 3,386 unique individuals, according to Erika Dalton, a paramedic who directs the county’s community paramedicine program.
Some residents called far more often than others. In 2025, 230 people called 911 at least four times, while 466 called twice and another 173 called three times, Dalton said.
It’s not just rural Virginia that has this problem. Nationally, the EMS workforce is burning out, in part from the sheer number of calls, according to a study published in Journal of Emergency Medical Services.
A national study found that a small subset of patients who call 911 — about 3% — account for 16% of all 911 EMS encounters. Nationally, the median time between encounters was 10 days for very high users.
These pressures also affect fire departments. Since the 1970s, more fire departments have implemented a dual-role model in which firefighters also serve as EMTs. As fire suppression and education have improved, medical aid calls have far outpaced fire calls.
In 2024, about 65% of fire department calls required medical aid, while 3% involved fires, according to data from National Fire Protection Association. Many of those medical calls, however, do not involve true emergencies.
The growing demand has contributed to compassion fatigue, burnout and turnover among fire and EMS workers, Dalton said. And the pressure will only increase in the future. The challenge will be finding ways to serve patients more efficiently, she said.
In Pulaski, residents face barriers common in rural communities across the country, Dalton said. Things like social isolation, limited transportation and shortages of primary care all create barriers to maintaining health. Older adults, who face greater risks of isolation and transportation challenges, can be among those who rely on the 911 system more frequently.
The repeat 911 callers reveal high levels of medical need, social vulnerability and gaps in healthcare.
“In EMS, we make contact with these individuals in their environment, so we see it firsthand,” Dalton said. “We have a unique perspective into these individuals’ lives — their households, their families and what they’re really facing.”
That perspective can help community paramedics identify the services patients need. They can connect people with other providers and resources or work with family members to help them better support one another.
Since Pulaski launched its community paramedicine program Jan. 1, about 70 people had been referred to services like a local friendship cafe for seniors, local social services and Medicaid transportation services as of early August, Dalton said. The program has closed about 30 cases.
For those closed cases, the results were dramatic. In the three months before entering the program, those patients collectively generated 200 EMS calls. In the three months after community paramedics intervened, that number fell to 11, Dalton said.
Community paramedicine programs like Pulaski’s can help fire and EMS agencies reduce repeat calls and free ambulances to respond to true emergencies. Dalton also said the work is incredibly fulfilling.
“It’s contributed to a lot of growth and maturity, not only as a provider, but as a person, to be able to get on their level and understand what they’re dealing with,” Dalton said. “It’s been remarkable, and I think any provider should have the opportunity to do that.”
Despite those successes, communities that could benefit from community paramedicine may face significant barriers to starting and sustaining a program.
Reimbursement for community paramedicine through Medicaid remains limited and inconsistent from state to state. Virginia Medicaid does not cover these services, and Pulaski’s program does not charge patients.
As a result, agencies must find other ways to pay for the staff, training, vehicles and equipment needed to operate a program.
Community paramedicine saves money, but it doesn’t generate revenue
In Pulaski, county leaders saw enough potential in community paramedicine to invest in it.
The county administrator, Jonathan Sweet, supported the idea and made general fund money available to launch the program, paying for Dalton’s salary, training and outfitting a new vehicle for her work. The initial startup costs came to about $170,000, Sweet said.
She’s even traveled around the state to see paramedicine programs in Northern Virginia and Chesapeake. The county now funds the program entirely through its general fund.
Danville has taken a different approach. Carroll and his team have relied largely on a local grant, which provides approximately $123,000 annually. The grant has supported the program for about five years and will expire at the end of 2026.
In total, it costs about $200,000 a year to keep the community paramedicine program running, according to Johnny Mills, chief executive officer of the Danville Life Saving Crew.
Community donations provide some additional support, but agency leaders are searching for a new, sustainable funding source, Carroll said.
That challenge can be even greater for rural localities with volunteer fire and EMS agencies operating on thin margins, according to Brandan Arthur, chief of the Vinton First Aid Crew, a mostly volunteer EMS agency.
Community paramedicine is on Arthur’s wish list, but building up the necessary resources feels out of reach.
Community paramedicine programs may reduce costs by helping prevent unnecessary 911 calls, but the programs do not generate revenue, Arthur said.
For volunteer EMS agencies, money is only part of the challenge.
Volunteer organizations may not have the staffing capacity to dedicate someone to building and running a community paramedicine program. Starting one requires more than asking a paramedic to take on additional responsibilities. Someone needs the time, capacity and commitment to identify community needs, build partnerships, connect patients with services and sustain the program.
Volunteer EMS providers already face significant demands, Arthur said. Staying current requires ongoing training, maintaining certifications and keeping up with the other responsibilities that come with providing emergency medical care.
Volunteerism itself can become a “massive undertaking,” he said, and some people simply cannot devote the time required to meet those responsibilities. Adding a community paramedicine program creates another layer of training and work.
That creates a difficult paradox: Community paramedicine could help reduce the strain on ambulance crews by addressing the nonemergency problems that repeatedly bring people to the 911 system. But for volunteer agencies already struggling to recruit enough people to maintain emergency coverage, finding the money, staffing and sustained capacity to launch another service may be out of reach.
Limited federal guidelines makes it easier to create tailored programs
There is no national policy to reimburse community paramedicine services, according to the National Rural Health Association. That lack of consistent funding can make it difficult for these programs to get off the ground and remain sustainable.
But the limited federal guidelines also gives localities the flexibility to build programs around their communities’ needs, Dalton said. In Pulaski, for example, health literacy is a significant challenge, so Dalton focused on education when she started developing the program.
In Danville, Carroll’s training was similar to that of community health workers. He describes the program as “a hand up instead of a hand out.”
The Virginia General Assembly introduced legislation in 2025 to assess Medicaid reimbursement for community paramedicine services. The legislation included two appropriations of $50,000 to the Department of Medical Assistance Services to develop a plan for reimbursing community paramedicine services in Virginia.
For now, local fire and EMS agencies with the resources and flexibility to develop and fund these programs are largely doing so on their own. Reimbursement from Medicare and Medicaid could provide more stability for programs that have shown promise in reducing repeat use of 911 and EMS services.
For Fitzgerald, the value of the Danville paramedicine program is less about the broader debate over how these services should be funded and more about the help she receives at home.
When Carroll stepped up to offer her the extra support she needed, her health, home and community improved.
In the last month, her son, who lives with her, found a nearby church where they now attend services together. These outings have made a world of difference for Fitzgerald, who may not have been able to participate in them before she had regular doctors’ appointments and more suitable living arrangements.
“It’s truly been a blessing,” Fitzgerald said.
