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Missouri Emergency Medical Services Association

RHT Pillar 3: EMS Agency Collaboration / Consolidation

Infographic explaining how EMS agency consolidation moves rural communities from siloed services to a unified EMS system and stronger health outcomes. Full transcript follows.

Infographic Transcript

EMS Agency Collaboration / Consolidation for Rural Health Transformation Program

Tagline: Stronger Together. Better Care. Healthier Communities.

From Siloed Services

Multiple agencies. Limited resources. Duplication of effort. Uneven coverage.

  • Variable levels of service and equipment
  • Higher costs and administrative burden
  • Recruitment and retention challenges
  • Gaps in coverage and response times

Through Strategic Consolidation

Align resources. Standardize operations. Build a unified, high-performing EMS system.

The unified EMS model includes:

  • Governance
  • Operations
  • Fleet and equipment
  • Clinical excellence
  • Finance and sustainability
  • Workforce

To a Stronger Future

One mission. One team. One standard of care. Better outcomes for every community.

  • Consistent, high-quality patient care
  • Stronger workforce and retention
  • Improved coverage and faster response
  • Greater efficiency and cost savings
  • Healthier communities, better outcomes

The Power of Consolidation

  • Stronger Together: Unified leadership and governance drive better decisions.
  • One Team: Shared culture, training, and values build a stronger workforce.
  • Better Coverage: Optimized deployment ensures faster response for every community.
  • Smarter Investment: Pooled resources reduce costs and maximize impact.
  • Sustainable Future: A resilient EMS system that grows stronger for generations.
  • Better Outcomes: Improved access, better care, and healthier lives.

Closing Statement

One Mission. One System. Better Health for Rural Missouri.

Diagram showing EMS Collaboration/Consolidation: regional integration leads to financial support, which enables service expansion.

EMS Collaboration/Consolidation Vision

To build a coordinated, resilient, and sustainable EMS system that:

  • Aligns EMS agencies into multi-county regional systems
  • Stabilizes rural EMS through shared governance and resources
  • Integrates EMS fully into healthcare delivery and MIH-CP models
  • Eliminates inefficiencies caused by duplication and fragmentation
  • Ensures equitable access to high-quality care across all regions

Jump to:

IMPORTANT NOTICES:

  • Anticipated Notices of Award. [Updated September 22, 2026.]

    The review and scoring of MIH-CP System Expansion & Care Delivery Transformation applications is underway. To conduct a fair review and to ensure equitable distribution, this review will take some time. MEMSA cannot guarantee a specific award date but is targeting between October 1 and October 12, 2026. Notice of Awards is also contingent upon the release of the Rural Health Transformation Program funds to MEMSA. Monitor this webpage for t updates.
  • The EMS Agency Collaboration/Consolidation first Application Cycle will close September 30, 2026. [Updated September 22, 2026.]

    No newly submitted applications will be accepted for Cycle 1 after this date.

  • Rolling Application Review and Funding Availability. [updated September 22, 2026.]
    EMS Agency Consolidation applications are accepted and reviewed on a rolling basis, subject to the availability of funds within each applicable budget period. Multiple funding cycles may occur within a budget period. Eligible applications are considered for funding as they are received and evaluated in accordance with the requirements and selection criteria outlined in the request for applications.

    Applications received after September 30, 2026, will be carried forward to Cycle 2 for review and funding consideration, subject to continued program eligibility, availability of funds, and any applicable program requirements.

    While applicants are encouraged to submit fully completed applications as early as feasible, for the next cycle, please check with the MIH Pillar Lead prior to submission. MEMSA is working toward submission of applications through an official grant portal for the upcoming cycle but is not sure how quickly the portal will be live. Check Important Notices on the RHTP pillar webpages for additional notices or contact the EMS Agency Consolidation Pillar Lead for updates. As a reminder, submission of an application does not guarantee funding.

    The Missouri EMS Association reserves the right to establish and announce application cutoff dates based on the availability of funds and the volume of eligible, fundable applications received.

Who Can Apply

Participating Agencies

Priority given to:

  • Rural agencies in high-risk or unstable regions
  • Agencies impacted by hospital closures
  • Agencies willing to:
    • Consolidate
    • Share services
    • Align regionally

Regional Proposals Must Include

  • Regional design model
  • Governance structure
  • Financial plan
  • Workforce integration plan
  • Alignment with:
    • ToRCH Hubs
    • MIH-CP expansion

Selection Criteria

  • Demonstrated need
  • Regional impact potential
  • Readiness for implementation
  • Sustainability plan
  • Cross-sector partnerships

EMS Collaboration/Consolidation will be implemented in a 2-phase approach:

Phase 1:

  • Assessment & Readiness
  • Planning & Design

Phase 2:

  • Implementation
  • Optimization

Key Funding Details

The EMS Collaboration/Consolidation funding will be awarded through a competitive application process. You must use funding to support EMS collaboration and/or consolidation, combining two or more districts into one regional district where appropriate.

How To Apply

Applications are accepted on a rolling basis and are reviewed monthly by the MEMSA review committee. Funding recommendations are based on application completeness, project readiness, alignment with program priorities, and the availability of funds. Applicants may choose to apply for funding for Phase 1 only or for Phases 1 & 2 combined. The budget should reflect expenses accordingly.

Applicants should anticipate receiving a Notice of Award (funding decision) within approximately 30 days or sooner following the monthly review in which their application is considered. Applicants may be contacted during the review process to provide additional information or clarification if needed.

A complete application at the time includes (this could change as the program develops):

Completed applications and supporting documents should be consolidated into one email and MUST be emailed to: rhtp@memsa.org. This is the official application submission portal.

Priority given to:

  • Rural agencies in high-risk or unstable regions
  • Agencies impacted by hospital closures
  • Agencies willing to:
    • Consolidate
    • Share services
    • Align regionally

Regional Proposals Must Include:

  • Regional design model
  • Governance structure
  • Financial plan
  • Workforce integration plan
  • Alignment with:
    • ToRCH Hubs
    • MIH-CP expansion

Selection Criteria:

  • Demonstrated need
  • Regional impact potential
  • Readiness for implementation
  • Sustainability plan
  • Cross-sector partnerships

Resources For Your Application

Frequently Asked Questions (FAQs)

Read this along with the RHT EMS Workforce Development and Sustainability Request for Application (RFA).

General Overview

Missouri law was amended in 2026 to improve the process for ambulance districts that want to join together as a single district. This process of consolidation begins with a petition by the voters of both districts or by resolutions from the current boards of each district. There must be a consolidation plan, with certain information worked out in advance, and the plan and petitions or resolutions are then filed with the county clerk. A public hearing is required, and individuals then have the chance to file written objections. If there are no objections, the consolidation simply moves forward by order of the county commission. If there are citizen objections, a public election is held to make the final decision. This process ensures a fair and open discussion of all of the benefits and concerns that may accompany consolidation of several ambulance districts.

What are the expected outcomes of EMS Agency Collaboration / Consolidation funding?

  • System Stability
  • Improved Operational Performance
  • Workforce Impact
  • Financial Impact
  • Patient Impact

Initiating the Process

The consolidation process can be initiated either by the voters of the existing districts through a petition or by the existing boards of directors passing a resolution.

No. The law requires that both districts approve of the proposal for consolidation, either through the actions of their citizens in signing a petition, or by formal approval of a resolution by the board of directors. The law does not allow for a hostile takeover of any ambulance district.

A petition must be signed by a number of voters equal to 10% of the vote cast for governor in the existing district during the most recent election for state governor. For example, if the residents of the district cast 13,785 votes for the office of governor in the most recent election, a minimum of 1,379 signatures would be required.

The petition or resolution must be filed with the county clerk in the county where the territory or the greater part of the proposed consolidated district is located. The county clerk will the verify that the appropriate number of signatures were obtained.

Yes. Each district that wants t consolidate must submit its petition or resolution during the same calendar year. If all participating districts do not do so, the consolidation effort is void and must be restarted.

The Consolidation Plan

Every petition or resolution must include a consolidation plan outlining the process for the proposed consolidation.

At a minimum, the plan must include the name of the proposed consolidated district, its legal boundaries, and the proposed tax levy. It must also list the names of the districts being consolidated, their current tax levies, and an inventory of their real property, financial assets, outstanding bonds, and debts. Can/will a template be developed for this?

The consolidation plan must specify which district will maintain ambulance services, continuing operations, administration, and governance during the transition. The law presumes that the district with the largest operating budget in the prior year will be responsible for maintaining ambulance service during the transition, but the consolidation plan can specify any of the participating districts to serve in this role.

The plan must detail the specific individuals who will serve as the initial members of the board of directors. These directors must be selected from the existing board members, ensuring that at least one director represents each of the districts being consolidated. Once the plan is approved, either by the county commission, if there are no objections, or by a vote of the citizens, the county commission will order these individuals are appointed as the initial directors.

The consolidation plan must include a proposed timeline that does not exceed 180 days. However, the consolidated board may modify this timeline if there is good cause.

Public Notification and Hearings

Each district must post a notice of intent to consolidate in the same way they post notices for district public meetings. Additionally, a notice must be published once a week for two consecutive weeks in a newspaper of general circulation in every county where the proposed district will be located. Do we want to include that they must show documentation of all these things having occurred?

Yes. A joint public hearing must be held by all the districts seeking to consolidate. This hearing will allow the public to learn about the benefits of the consolidation plan and how it will help ensure high-quality emergency ambulance service for the citizens. The public will also have the opportunity to express their own concerns and opinions about the process.

The hearing must take place at a location within the boundaries of the proposed consolidated district and must be held no more than 30 days after the second newspaper publication of the notice.

Filing Objections and Elections

No. An election is required only if written objections are filed with enough voter signatures. If no sufficient objections are filed within the statutory period after the public hearing, the county commission orders thee consolidation under the terms of the consolidation plan and appoints the initial directors for the consolidated district.

Yes. Any objections to the consolidation can be filed in writing with the County Clerk within 30 days after the public hearing. If no objections are filed, the county commission can proceed to order the consolidation without an election.

An objection must be signed by a specific number of voters residing in the proposed district. This number must be at least 5% of the votes cast for governor in the district during the most recent election for state governor.

If no objections are filed within 30 days of the public hearing, the county commission will formally order the districts consolidated according to the plan within 45 days of the hearing. The commission will also appoint the directors identified in the plan.

If the necessary amount of voter signatures are verified on the objections, the county commission will order that the question of consolidation be put to a vote for the public to decide.

If the issue is submitted to the voters, the consolidation will pass if it receives a majority of the votes cast.

Taxes and Finalizing Operations

Without a vote by the residents, the newly consolidated district is not allowed to impose a property tax or sales tax that is higher than the lowest existing tax rate among the districts being consolidated. That means that the lowest rate currently in place would be adopted for the entire consolidated district.

Yes, but only if approved by voters. The consolidated district may levy an initial tax up to the highest eligible tax levy of the consolidating districts, provided that specific tax levy was clearly written in the ballot language and approved by the voters.

The consolidation plan must list each district’s real property, financial  assets, outstanding bonds, debts and current tax levies. Once the old districts cease to exist, all assets and obligations become assets and obligations of the consolidated district.

The existing ambulance districts will legally cease to exist once the new consolidated board provides written certification that they have obtained the necessary licenses and permits to operate and that all directors have completed the required training. At that point, the consolidated district assumes all powers, assets, and obligations of the former districts.

Allowable Uses of Funds

There are several uses of funds, not all of which are stated below. Some examples, however, include:

  1. Personnel – primarily someone to serve as a project lead or project coordinator.
  2. Fringe/benefits for any employed personnel.
  3. Equipment for standardization and operational communication fees (e.g., radios may need to be standardized).
  4. Contracted professional fees, such as attorney fees, auditor/auditing fees, data analyst, etc.)
  5. Travel for attendance at local, state, or regional meetings, or professional development related to EMS consolidation.
  6. Other expenses that may be budgeted include election costs, public relations/social media promotion, board meeting costs for additional board meetings, new entity operational licensing and certification fees, policy/protocol standardization and publishing, rebranding, and more.

Professional Association membership dues – becoming a member of state and national organizations that can provide professional education and peer networking opportunities to aid with EMS Consolidation

Yes, but you must justify how it is necessary for EMS Agency Consolidation. Reviewers may negotiate, depending on costs associated with health information technology requests.

Yes. Funds may be used for recruitment incentives to ensure appropriate personnel are available to support services once agency consolidation occurs.

Budget Requirements

Funding requests may vary based on need, but the maximum request is not expected to exceed $250,000 for 12 months.

Please refer to the budget template that provides examples of the types of information that may be included in the budget. For personnel, it is important to prorate their time based on the number of months they will be employed during the project period. For example, if the project period is August through July, but the individual will not start until October 1, budget for only 10 months of the individual’s salary (October through July). 

Yes, but you must justify how it is necessary for EMS Agency Consolidation. Reviewers may negotiate, depending on costs associated with equipment requests.

Yes, organizations that would qualify for support of membership dues and travel support to attend a conference for professional development include:

Missouri: 

National:

Other

You are encouraged to seek counsel from your CPA about whether any funding awarded from RHT will have an impact on your threshold for triggering a single audit. You are encouraged to explore further education on audit requirements, particularly if funding will trigger a single audit. You may also need to consider the costs of a single audit when applying for RHT funding.

Budget Presentation

REQUIREMENT: Use this budget template to develop a complete and accurate funding request for your EMS Coordination/Consolidation project. You MUST select whether you are applying as a PHASE 1 or a PHASE 1 and 2 combined project, then complete all budget categories based on your program’s needs.

Applicants are required to submit a budget for a three-year project period to demonstrate anticipated project costs. Initial awards will provide funding for Year 1 only. Funding for subsequent years (Years 2 and 3) is subject to the availability of federal and state appropriations, satisfactory performance, and continued programmatic need. Additional continuation funding for up to two more years (Years 4 and 5) may also be available under the same conditions, for a maximum project period of five years.

Key guidance includes:

  • Prorate personnel costs based on when staff will begin EMS Coordination/Consolidation project activities. Contracted personnel should be included under the Contract budget category.
  • Include an overall fringe benefit estimate (detailed calculations should be retained for audit purposes).
  • Funding may support items as outlined in the sample budget template.
  • While not required, identify any leveraged or in-kind resources that support the project.

Replace all placeholder values in the template (e.g., “XXXXX”) with actual figures, FTEs, percentages, and verify that all formulas and totals calculate correctly before submission.

Find Technical Assistance / Contact Us

If you have a question about EMS Collaboration / Consolidation, please send your inquiry to the attention of John Barclay, Program Lead, EMS Agency Consolidation Pillar, at rhtp@memsa.org. Please use this address, as it is the official portal for RHTP inquiries.

  • Developing Your Application
  • Budget
  • Application Submission

Disclaimer

This webpage is intended as a summary only. The applicable Request for Application, award agreement, federal and state requirements, and any MEMSA-issued written guidance control in the event of any inconsistency. MEMSA reserves the right to modify, clarify, suspend, or cancel funding opportunities, requirements, award amounts, timelines, or allowable uses as required by law, funding availability, program requirements, or administrative need.

MEMSA may reject applications that are incomplete, nonresponsive, inaccurate, late, or inconsistent with program requirements. MEMSA may request clarifications, negotiate budgets, impose conditions, reduce requested amounts, or decline to fund any application. Applicants and awardees must comply with applicable conflict-of-interest, nondiscrimination, procurement, privacy, reporting, and record-retention requirements.

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