'Behind the Blue': Researchers Study Rural Ambulance Services, Health Care Access

NARRATOR: From the campus of the University of Kentucky, you're listening to Behind the Blue.

KODY KISER: When hospitals close, we can assume that those who live near them will presumably have less access to medical care because they will have to travel farther for health care services. Since 2009, five rural hospitals in Kentucky have closed and many more are at risk of following suit.

Alison Davis, a professor of agricultural economics in the College of Agriculture, Food and Environment, and Director of Community and Economic Development Initiative of Kentucky, or CEDIK, and SuZanne Troske, a research associate at CEDIK, recently authored a policy paper, and are working on a research article that discusses the impact rural hospital closures have on the length of time an individual spends being transported in an ambulance.

While the paper didn't offer specific solutions to the problem, the two researchers plan to conduct further studies to examine air transportation as an alternative. How longer ambulance rides impact health outcomes and understand the importance of hospitals as an economic driver in a community.

I'm Kody Kiser with UK PR and Marketing, and I'm joined this week by UK PR's Carl Nathe and Olivia Ramirez. On this week's episode of Behind the Blue, Davis and Troske join us to discuss all of this, as well as the role communities can play in keeping rural hospitals open, the important piece of health care services provided by ambulances, and emergency medical services, and how economic development can impact health outcomes.

So we like to jump into this with a little bit of background on the people that we talk with. So first of all, tell us a little bit about-- well, what you toss a coin or arm wrestle or thumb wrestle, however you want to go about it-- rock, paper, scissors. How did you-- how did you arrive at the University of Kentucky? And tell us a little bit about the work that you do in a kind of a general sense.

ALISON DAVIS: OK. I'll start. So I-- my background is in regional economic development. And I moved here from the University of Nevada, Reno. And was excited to come to University of Kentucky where my area of expertise is economic development and rural health. And I'm an extension specialist, so that means that I have joint programming both for research, as well as engagement and outreach with extension agents and communities, leaders, hospitals, all folks with probably a little bit more focus on rural communities, because that's where the needs have emerged.

CEDIK is an integrated research and Engagement Center that's housed within the University of Kentucky in the College of Ag, and it's comprised of several departments within the college, including community leadership development and landscape architecture. And we have about 14 staff that are dedicated to needs that emerge throughout the state, the Commonwealth, specifically, in the area of economic development, community design, rural health, and leadership development.

SUZANNE TROSKE: I'm Sue Troske. I've been here at UK about 12 years. I've worked in various departments from-- and I've studied things from rural education with the Martin School and got really interested in that. And then I had an opportunity to go to the College of Pharmacy where it's sort of my journey on doing health research-- health policy research. Started looking at drug policy within the state, looking at prescribing habits. I did a whole paper on meth labs in the area.

And then Alison offered me a job. And now I've started-- moved into looking at hospitals and ambulance services and sort of expanding my knowledge of health care policy in Kentucky and across the nation.

KODY KISER: This-- it feels like there's a lot of facets to this, and a lot of territory to cover. How do you-- how do you keep all of that stuff-- I mean, it seems so intertwined and so-- the complexity of how everything that you research is layered on top of each other, and how one thing affects something else, affects something else. How do you-- how do you sort through that to figure out what is the most important thing, or what is the thread that you follow in some of your research in a sense?

ALISON DAVIS: I think for me, particularly, we try to focus on the root cause of issues as opposed to symptoms. I mean, certainly symptoms need to have band-aids, and we need to try to minimize symptoms. But I find a lot of folks focus on learning about symptoms when, in fact, the root cause is really the issue. And so we try to really get down in the weeds about what would it take for essentially rural prosperity? And that typically says we need to have folks who have economic opportunity, equity, access to health care, and access to good education and housing. So we're really focused on the nuts and bolts.

And while we know a lot of folks focus on diabetes research and obesity, a lot of that comes about because of a lack of economic opportunity and a stable income. And so we tried to really focus on the kind of foundational infrastructure as our first go. But they are all intertwined, and we recognize that. And we try to get our communities to recognize, particularly, the relationship between economic development and access to health care. That those two have got to go hand-in-hand. You cannot think of them differently.

KODY KISER: Well, considering that we just had a little bit of ambulance noise in the background, one of the things that we wanted to talk about was the recent research in the paper on rural ambulance services and the impact between that and rural hospitals, as well. Talk-- let's kind of jump into that and talk a little bit about the formation of that and kind of what the-- where the research kind of led you with this.

SUZANNE TROSKE: Well, the question came up-- it's sort of obvious. If a hospital closes, are you longer in an ambulance? Nobody had really studied that before. So I started in on the project. We started in on the project and found out the complexity of ambulance services and the heterogeneity of ambulance services across the country, even within our own state, is just amazing how one-- one community will have it supported by the fire department and through tax dollars, another will have-- a nonprofit will be supporting their ambulance service, another is a private industry.

And then how they transport people across counties and across cities and between cities. And it's just-- it's been really fascinating industry. And there's no-- there's sort of no overarching model. And it's sort of forgotten piece of health care as far as from the federal government, and even at the state level. We think of maintaining emergency rooms, but we don't talk about how people get there.

I mean-- and so when a hospital closes, one thing you hear over and over again is I'm on an emergency room and I can't go to the next area because I can't get there. And I think transportation is just so important. And I think ambulance services are a big part of that transportation puzzle.

MALE INTERVIEWER: If I might interject-- so it's a big thing where you live if you are able to live in a place where you can get to the hospital emergency room in 10 minutes, that's a lot different than you might be an hour and a half away from a hospital.

SUZANNE TROSKE: Yeah. And a lot of it is convenience. I don't want to comment directly on your health-- the health outcomes, because we've seen positive and negative. But just we see a lot of stress with people. You know, now your loved one is 25 miles away rather than 10 miles away. Or you don't know how to get them or you delay. There's some research that you delay calling the ambulance because it's just too big of a burden.

So it's just trying to understand that puzzle and make-- and part of the emergency care system in this country. It's been really fascinating to me.

ALISON DAVIS: And I think as our rural communities continue to kind of suffer from some population loss, that means their tax base is going away. And so that puts continued pressure on being able to provide services to its residents. And so now if you have a hospital that closes and an ambulance takes you to a hospital, it is now out of that service area. And so if another emergency occurs, if there's a car wreck or a heart attack or what have you, now-- now you're in real dire straits. Because the one ambulance that was there is now up in Lexington or Louisville or wherever. And so it's just a kind of a bunch of forces together that could create-- particularly as we continue down this path of population outmigration and rural communities that it could really create some significant issues.

SUZANNE TROSKE: So kind of what brought this research question to the forefront of your minds, is it related to previous research you've done or just does you have an experience that kind of motivated you to study this?

ALISON DAVIS: Well, we have a pretty strong relationship with the Kentucky Hospital Association and the Kentucky Office of Rural Health. And certainly their mission is to be able to provide quality services to rural communities. And the last four or five years we've just seen a real significant increase in the number of rural hospitals that have closed around the country.

Kentucky for the most part, has fared relatively well. Sue, how many hospitals have closed?

SUZANNE TROSKE: We have five hospitals since 2009.

ALISON DAVIS: Yeah. So Kentucky has fared OK. We still have a significant number of hospitals that are considered financially risky right now. And we do a lot of work in our rural hospitals, they're a significant employer for our communities, they pay great jobs, and certainly they provide needed health care.

And so we are always on the cusp of trying to highlight to policymakers, to economic develop professionals, that this is something that we need to ensure is sustainable. Or that at least folks have access to emergency care, because that seems to be what is really most important.

And we had done a study back in 2012, where we surveyed rural residents and said, what's really important for you when you receive health care? And what's your willingness to pay for it? And at the end of the day it really was, we want to ensure that we have access to an emergency room.

We don't need it right now, but we really want to make sure we have it. And for employers who are thinking about moving in an area, particularly if it's manufacturing for farmers, they need to know that there's somewhere nearby for their workers, for their families, if something goes wrong. So we've done a lot of work in rural health care, rural hospital closures.

And then we're part of the rural and-- help me out here.

SUZANNE TROSKE: Underserved Health Research Center, which is funded by the Federal Office of Rural Health Policy. And we're in a group with people from the College of Pharmacy and the College of Public Health and the American Physicians Group. And it's been great, because it kind of combines our rural hospital and ambulance service work with-- and suicide prevention in rural areas, and opioid addiction, and black lung, are some of the other things that they've studied there. So it's a nice overarching look at health in these rural areas.

ALISON DAVIS: And this was a topic that showed up as being important to the Federal Office of Rural Health Policy a couple of years ago. And so they had asked us if we had the capacity to expand our research on rural hospital closures by including this as a topic.

INTERVIEWER 3: I've heard an old adage when it comes to studying problems and solving problems that, if a problem is local, the solution can be found locally. But this sounds like this might be beyond that realm.

SUZANNE TROSKE: I think a lot of-- from my standpoint, a lot of the incentives are set up by the Medicare and Medicaid Reimbursement Policies. And that comes from the federal level.

For instance, ambulance services, you have to ride in an ambulance in order to get reimbursed. If they show up, you decide that you don't need a ride, they don't get reimbursed for it. Which is really difficult for a small community ambulance company to deal with.

The Department of Health and Human Services is looking to change that. And that would be fabulous for rural ambulance services, because they could actually treat you on-site.

One common thing is administering Naloxone for people who have had an overdose. You could treat them on-site. Now you have to take them in a truck, and take them to an emergency room. But you could actually treat them on-site and still get reimbursed for it.

So I think it's all money, it's all financial. So these hospitals are closing because they don't have enough money. And a lot of it is Medicare. And they rely on Medicare and Medicaid reimbursements. And it's the Medicaid and Medicare reimbursement formula that's affecting these hospitals.

ALISON DAVIS: And I think there's a local, a state, and a federal position on these issues. Because Sue had also done some research that looked at, what's the optimal ambulance service type? And we were measuring what's optimal in terms of efficiency in getting a patient to the hospital? And so I think there's some local things to think about.

How to support your local hospital. How to create a really sustainable EMS ambulance service. There are some state and also certainly Sue touched on the federal issues. So I think it's a really complex issue. I don't think it can be solved solely at the local level, but I think they certainly can be a part of the conversation.

INTERVIEWER: So would you say this research was a bit more focused on just understanding the extent of the problem, or do you have any recommendations based on what you all found?

ALISON DAVIS: On the-- oh, the hospital closures and time in an ambulance? I don't know. Policy recommendations.

I think the new policy that they're introducing, where they can treat you on site, I would make that a recommendation, because then obviously your time in an ambulance would go to zero, would be great.

I think we just wanted to understand the magnitude of it. I don't think we had any direct policy-- we have done some other work. We're trying to look-- this idea of understanding who uses the ambulance. And so to understand who really uses the ambulance, helps you set your policy on how you do reimbursement.

So another work we're doing is trying to understand, do older people use it more? Do remote people use it more? Do more suburban people use it more? To see how when-- so when you think about a reimbursement model, and you look at who's using it, is it all Medicare people who are using it?

OK, well, then you need to talk about your Medicare reimbursement. If it's all Medicaid people using it, then you need to talk about your Medicaid reimbursement models.

INTERVIEWER 2: Is there an impact on this to some degree from-- we talked about-- you were talking about some of these areas that-- when you think about there's not a lot of industry and not a lot of work in some of these areas and in some communities, the medical facility is the primary economic driver to some degree. It's not like an urban area, where you have a lot of things that are interconnected, that if one thing suffers a bit there are other areas.

Is there anything to the idea that oftentimes people decide that they don't want an elective treatment at a local regional place? Which then also causes an impact-- kind of, a depressing impact, because the hospital facility or the medical facility is also not for-- the idea of walk-in patients who are electing to have treatment there, which is an interconnected. Is there anything to that?

ALISON DAVIS: Yeah. There is a fair amount of research that suggests that rural residents tend to bypass their local hospital. And in a lot of our rural areas, we have what are called, critical access hospitals. And certainly when someone comes in with a significant trauma, the role of that hospital is to get them stabilized, and then if the trauma is significant enough, they do get transported on to the higher level trauma centers.

Hospitals today, as a mechanism for generating additional revenue, have really tried to focus on some more outpatient services. And so you see now they try to bring in specialists, they try to have radiology, they try to have some additional diagnostic services.

And at this point, the need of the community and the hospital to have a conversation, so that the community members know that it exists, and the hospitals can get some foot traffic coming in-- and also working with the local providers so that they refer their patients locally, as opposed to out of the area.

So we have-- over the last six or seven years, we've been doing community health needs' assessments for almost all of our rural hospitals in Kentucky. And a lot of the committee members will say, oh, we need to have this specialist, we need to be able to stay locally for dialysis. And then we say, actually, the hospital provides those services. And so it's really that two-way communication.

Because I think the future of hospitals is really being able to provide these ancillary services as a way to generate additional revenue. And something that happened 30 years ago-- someone's grandma went to the hospital 30 years ago, had a terrible experience, and that continues. That history somehow is still the reason why people have chosen to not go to that local hospital, despite its wonderful quality ratings now. So there's a lot of potential, but we have some barriers we need to overcome.

INTERVIEWER 3: So the perception is still there that it's was what it was 30 years ago?

ALISON DAVIS: Yeah. It's amazing. And they will write-- we did a study on bypass behavior. And said, why, why are you going to this hospital? Well, my great grandma, she went there and she had terrible service.

I said, well, all those providers have likely passed on to better places. And we have some really great quality programs that the Kentucky Hospital Association runs. And a lot of times rural hospitals actually fare better in many of those indicators.

And so I think there is a perception that the quality isn't as good. And certainly not-- every hospital's different. But for the most part, they do really well. And so it's just trying to change that perception.

INTERVIEWER 3: I might ask a broader question, and both of you could answer, one or both. When we talk about CEDIK, the Community and Economic Development Initiative of Kentucky. Which, Allison, you're a professor of Ag economics here at the University of Kentucky, but also director of CEDIK. And Sue Troske, research associate at CEDIK.

You're all about trying to help people that live in rural areas, have a better way of life. And there's so many advantages or pluses to living where it's not so congested. And yet, what you need is-- within that you've got to have some economic stuff driving things or else there's nothing to keep people there.

You've been able to make progress. But it's an ongoing battle. What about that? Maybe you want to address that first, Alison.

ALISON DAVIS: Sure. It is an ongoing battle, and there's no quick fix. We really try to have our communities understand what they are good at. What is their niche?

And not spend a lot of time and resources trying to go after the pie in the sky, which is something that we saw a lot of in the '70s and '80s when we were just trying to attract big industry. And the reality is that's not really going to be successful in a lot of our small communities.

And so in order to be successful, we need to have really good leadership in the communities, elected officials, hospital leaders, school leaders. So a lot of it is building local capacity, local leadership, focusing on existing businesses.

A lot of times our existing businesses are there, they see us going after these little fancy places that we want to have in, and we ignore existing business. And they're deciding to leave or shut down, and they don't get a lot of focus. So we really push focus on what we have, and make sure they're well-situated with focusing on entrepreneurship.

We have a big project with MIT about creating an entrepreneurial ecosystem. But for me it's all about leadership and it's all about community pride. And that's a big, big job. And that takes a lot of time.

And with that, we find places that have been very vibrant is where that has occurred. And you see some younger professionals who are stepping up into leadership roles, who bring a vision of a different type of community. And you see that, that really gets you places.

INTERVIEWER 3: Sue, any thoughts?

SUZANNE TROSKE: From the health care standpoint, I've seen-- there's a gentleman who went to a community in Maine and said, OK, you want an ambulance service. Well let me lay this all out for you. Let's look exactly at what service do you want, this is how much it's going to cost you, and let the community decide. And they decided to continue with their same service and that they were willing to pay for it.

The same with rural hospitals is let's decide what the community wants, but explain to them exactly how much it's going to cost them.

One thing that scares me about some of the rural hospitals is the communities take on debt for the hospitals. And then when the hospital closes, they're still holding the debt. And so the community has to understand that. That not only will they be holding the debt, they'll be losing the tax base.

And so I just think they really need to understand it. And once they make those decisions, then it's their decisions for their community.

ALISON DAVIS: Yeah. That community ownership is really key. And having full, transparent conversations about pros and cons. We see a lot of people swoop in and say, we're here to save you. That's kind of the motto.

And that not sitting well with rural communities anymore, because now they've said, we're going to own this, and we're going to bring in technical assistance and leadership as we see fit. So we need to know what kind of ambulance service do we have-- we're going to have those really pointed questions and make those decisions. But it really has to be community owned for it to be successful.

INTERVIEWER 2: Do you feel like there's a tie-in with that to some degree? With an encouragement that maybe the University of Kentucky does with funding students who-- we've talked about this a lot before, the importance of finding students who come from some of those communities who want to pursue medical careers, who want to pursue entrepreneurial careers, that they can take back to those areas.

We talk a lot about students who come from rural areas, who come to Lexington, and then they don't leave, or they move on to even larger urban area.

But there is a lot of benefit, and a lot of a, kind of, a reciprocal relationship to some degree of those students who come here and get that education and then go into those positions, as well.

ALISON DAVIS: Yeah. We find that everywhere we go they say, we just want our kids to stay here and come back. And they'll say, just like you do in Lexington. And we say, there are a lot of kids in Lexington who leave and don't come back. And so what we say, is you want to create an atmosphere where young residents want to go to, whether it's coming back, or new residents.

And so certainly it is critical to have some young folks going back into rural places to practice medicine. We see just down the pipeline it's a little bit nerve wracking to see that expected shortage. And we've seen some places, particularly in Appalachia, where there is kind of a surge of new young folks who are moving in.

Corbin's one example where we see a lot of folks who aren't from Appalachia, who have moved in, they've been accepted, and they're part of that movement towards the new economy. So it's not that we want our own kids, it's we want to create a place that nurtures all types of families, we want to be inclusive. And so yeah, that's really, really critical.

INTERVIEWER 3: Because not everybody wants to live in a place where there's high rise buildings, and loads of traffic, and other issues. There's a certain peacefulness and living your own life when you can be in a rural area. That really appeals to people, but they've got to feel accepted and part of the community.

ALISON DAVIS: They do. Even people in some places who have lived in a place for 40 years, and they're still known as someone who wasn't from here. And so in order to be one of those communities that can be progressive, you have to nurture and accept new residents. And so that's hard for a lot of places, where you have been built on a community of many families who have been together, who have supported each other. And you see new people coming in and change is always challenging, exciting and challenging.

So really trying to help communities understand that there is tremendous benefits that come when you are inclusive and you make people feel like they're home, even if they're not from here. Because I came to Lexington-- no one ever cares that I didn't come from Lexington. I was welcomed here and it's wonderful. And so we're trying to have folks understand how important that sense of welcome is.

INTERVIEWER 2: So the research, the paper has-- you've put the paper together and you've done this research. Where does this research go now? How do you build upon that? And what are the next steps for this?

SUZANNE TROSKE: So we've expanded this. I'm taking this hospital closure, time in an ambulance paper, we expanded it into more academic journal article. This is more of a policy brief. So I'm currently working on that and digging down a little bit more into the data, and being more careful, and using some more econometric techniques.

From this we've expanded into just looking at ambulance usage, and the difference in ambulance usage across the country, and across different rural and urban areas. And as I said, we're trying to understand who uses the ambulance by different characteristics, different regions of the country.

And then, Alison talked about, we have one looking at the ownership structure of the ambulance service and looking at efficiency. Who gets you there the fastest, but is it at the most cost-effective? We've discovered that nobody has the model for a community.

So we're struggling here in Kentucky. A bunch of the communities are now pooling and getting a private ambulance service. But I can't walk into a community and say, oh, you really should be funding it with tax dollars, and you should have three trucks, and you should be located 10 miles apart.

There's really no model and not a lot of help. Until this one person who did that thing in Maine-- the seminar in Maine and had them really talk about it and go through it. That was the first time I've ever really seen that. So the initial research has kind of expanded.

ALISON DAVIS: There's three other things, I think. A gentleman who works for the American Hospital Association contacted us and said, this is really interesting. We see a lot of our communities are now turning to air. That the ground transportation has gone away. And so now they're relying on air.

Well, air is slightly expensive. And it's a challenge to really think about logistically. So thinking about that as a question.

One of the questions that we weren't able to answer in this study is about health outcomes. So does this mean that I'm just spending more time in the ambulance, and that's all good, or does this mean that I'm at greater risk of permanent damage or death?

And so we have an opportunity just within the state to look at a subset of data to see, can we see if there are really any health care outcomes for folks who have heart attacks or stroke. So there is an opportunity for that.

We're also launching one more study with the Center for Business and Economic Research that's looking at the importance of hospitals as an economic driver. And so we're looking at, as hospitals have come and gone, can we actually see places-- their industry mix change, the quality of jobs change, and we're using the Research Data Center to look at that over a span of 40 years or so to see, is this-- we say it's important for economic growth, but can we say for certain, or are there certain characteristics that drive the success of a community. So we've got some exciting things coming up for sure that I think will help explain some of our unknowns.

SUZANNE TROSKE: It's a fascinating area. I love researching it. And it's just sort of never ending trying to put the whole puzzle together.

INTERVIEWER 3: And one thing that's important I think to bring out to our audience that's listening to this interview with Alison Davis, who is professor of agricultural economics, and director of the Community and Economic Development Initiative of Kentucky here at the University of Kentucky. And Sue Troske, who is a research associate at CEDIK, which is the acronym, the nickname.

But it's important to bring out that the whole reason that people study things is so-- if somebody listens and, well, OK, that's great, you're studying this. Well, the whole reason you're studying it is to really pinpoint, what are the problems. So that we throw-- if you want to look at it that way, we throw good money at the problem. We don't just guess and throw bad money, and don't get anywhere.

ALISON DAVIS: Exactly. I think this is all about finding a solution to a problem. And so we spend a lot of time throwing money at things. But I think these studies will really help us determine, what are some of the optimal strategies. And I don't think it's a one size fits all. And we treat things like it's a one size fits all. So hopefully our final recommendations will sort of follow along those lines that not everyone's the same.

SUZANNE TROSKE: Yeah. There's a lot of anecdotal evidence. Everybody's got anecdotal evidence. But we just sort of take all the evidence and study it all together and kind of understand it.

INTERVIEWER 3: Evidence-based.

SUZANNE TROSKE: Evidence-based.

ALISON DAVIS: Yeah. Sue's heard this story and this is why she says this, because I have my anecdote that-- a hospital that's now closed. But the CEO, who is someone who we had worked with, went up to Capitol Hill and said-- he was talking about the importance of his critical access hospital staying open. And he said that there was a time where an ambulance came to the front door of the hospital and the patient was coding.

And because the ambulance could get there, the staff was able to get him back to life and then get him transported on to UK, and he was alive. And so I always end with, that hospital has now closed. And so what does that mean? So it's just a big story. But that is just an anecdote. And so really to try to understand for the average person what does this really mean?

INTERVIEWER 2: I think something that really shines through for me here on this is just thinking about the fact that this has not been looked at before, the level of complexity involved in this. But just how much that effort means to other places around the country who are, maybe in some cases, geographically similar. That they have a couple of centralized urban areas, but they have a lot of outlying areas where there are maybe a smaller population, but a population that has a limited access, that is really desperate for some answers on how to handle this.

And I think that is really tremendous that this is such a dive into something that has just not been looked at before. And so hopefully you'll get a lot of response from a lot of other areas about it.

ALISON DAVIS: Sue, just talk really quickly about, the reason that no one's been able to look at that is because of the data. Now, Sue is sort of a master of what these data are.

SUZANNE TROSKE: So for the ambulance work, I've discovered the National Highway Traffic Safety Administration collects all the ambulance runs in the country. And they made that possible after 9/11, because they realized they just didn't have a lot of information about emergency services in the country.

So they've collected them at the University of Utah. And they've allowed us to use them. They're confidential data. We're not allowed to know the exact geography of them.

But if you figure out exactly how to work with them, we've been able to extract a lot of information and use these. And it's really interesting. They have all the parts of the ambulance call. So the dispatch time.

Alison is smiling because I can talk about this all day.

ALISON DAVIS: She's Miss Ambulance--

SUZANNE TROSKE: Yeah. And then like, the time at the scene and the transport time. And we've been able to break that up and look at how that looks when the hospitals open, when the hospitals are closed, by fire department, by community, non-profits. So it's been a really, really rich data set to use for us, and we've taken advantage of it.

INTERVIEWER 2: I do want to ask about that really quickly, and kind of wrapping this up. One of the things that-- I've heard you both talking about this before-- how you can break the data down and look at the time to response is a particular block of time. The time on the scene is a particular block of time. And then the time transporting.

And that's where I believe you-- I remember you're saying that was where a lot of the discrepancy comes from. That the time to response is pretty similar in a lot of cases. The time on scene is pretty similar. But it's the transport time after that really starts to play a critical role in this.

SUZANNE TROSKE: Yeah. And for rural areas, it almost doubles in the time. If you're in a community where a hospital closes then your transport time doubles. But I find it interesting, we're pretty standard across the country on the time to scene. It seems to be about eight, nine minutes that ambulance services will get to you, which I thought was interesting.

ALISON DAVIS: And it will be interesting in 20 years or 10 years to see if that has shifted. My hypothesis is eventually that will start to increase as communities start to really have some issues with local financing. If it is government finance and so forth. So it would be interesting.

We found a little bit that the time at scene was maybe a little bit longer. And we had some folks who gave us some feedback who were actually EMTs that said, if they know their trip to the hospital might be longer, they'll spend a little bit more time on scene stabilizing. So that was something that wasn't significant, but it was something that-- it was interesting to have someone tell us that, that was a possibility.

INTERVIEWER 2: Well, Alison Davis and SuZanne Troske, thank you both very much for being with us. If anyone who is listening would like to know more about the Community and Economic Development Initiative, where would they go to find out anything about this?

SUZANNE TROSKE: They can go to our website, which is cedik.ca.uky.edu or just go to the College of Ag and find us. Yeah.

ALISON DAVIS: So the rural research can go to the Rural and Underserved Health Research Center website.

SUZANNE TROSKE: Yeah. There's some really great policy papers that are coming out right now about pertinent issues in Kentucky, specifically, around substance use disorder. So we've got some great experts on campus who are tackling that.

INTERVIEWER 2: Well, thank you both very much for being with us. We appreciate it.

SUZANNE TROSKE: Thank you.

ALISON DAVIS: Thank you for having us.

NARRATOR: Thank you for joining us on this edition of Behind The Blue.

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