The History of the World of NorthStar
(How a Star was Born)
By David Robie (with Emily Brostek)
Rev. September 13, 2007
Executive Summary
Innovative. State-of-the-art. Progressive. All these words can be used to describe NorthStar, the full-service, regional ambulance system of Franklin Memorial Hospital.
Today, NorthStar has tremendous scope and presence in the community it serves. NorthStar operates out of five strategically located bases to serve 72 communities and 2,800 square miles in Northwestern Maine. This area touches five counties, encompassing all of Franklin County plus parts of Oxford, Somerset, Androscoggin, and Kennebec counties. Geographically, its territory comprises approximately 8.3% of Maine. In order to serve this vast region, which is home to about 40,000 people, NorthStar employs almost 100 paid EMTs to staff an average of seven ambulances around the clock. A NorthStar paramedic is present at substantially every service call, making an average of 5,300 runs per year.
Building on the heritage of the five predecessor services (LifeStar, CES, AMPS, Sugarloaf Rescue and Rangeley) that combined to create NorthStar in 2005, the regionalized service lives it mission:
"The professionals of NorthStar will adhere to the highest standards of respectful patient care, engage in positive community activities, and exercise good stewardship of our resources, all in the pursuit of excellence."
The process to blend the diverse services and to develop an operationally and financially viable plan was a multi-year task. Proposals were made, reviewed by constituents, adjusted, re-reviewed, and modified again until there was consensus. Implementation took communication, disclosure, information sharing and a steady management hand.
The result is a premier system and one of the largest in the state of Maine. Measured by geography covered, training, professionalism, response time, state-of-the-art equipment, NorthStar is considered one of the best.
Where we came from and how we got here is detailed in the following pages. Through these pages, we hope you gain an insight on the scope of the organization and the effort that went into its success.
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Today, NorthStar is a prominent presence in the community. Its Bike Team is present at community events, town festivals and school education programs, and staff is active in educational programs, Operation Santa Claus and Keep Maine Warm.
NorthStar has emerged as a respected, professional, and prominent organization in northwestern Maine. But this was not always the case. Before 2004, the Greater Franklin County Region was served by five separate and distinct ambulance services. Through the leadership and vision of Franklin Community Health Network, these five services were brought together in 2005 to form NorthStar. The story of that process is detailed in the following pages.
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Background of NorthStar’s Founding
Before the formation of NorthStar in 2005, this region was served by five separate and distinct ambulance services, each of which historically fed into Franklin Memorial Hospital (FMH). NorthStar is built on the heritage of these services and thus the story of NorthStar would not be complete without a little history about each of them.
First, some background about the beginnings of Emergency Medical Service (EMS). Most EMS services got their start as mortuary business using converted hearses. The hearses would show up at the accident scene expecting to take away the deceased only to find that the victims were still alive and needed transport to a hospital. Since the hearses already had space available in the back of the large Cadillac or Pontiac wagons that were often used, it was a natural progression to attach a red light to the top and start moving live patients. When used as a hearse, the red light was covered or unscrewed and removed. The early “ambulances” had no equipment and the drivers had no training – it was simply “load and go (fast)” to the nearest hospital. Because of space limitations, the patient was generally in the back alone although some care and comfort was given through the partition window between the cab area and the back of the vehicle.
As time went on, EMS evolved to what we have today. Eventually, the State government got involved. Maine EMS today is part of the Department of Transportation based on the early years of transporting only from auto accidents. Equipment standards evolved, as did protocols. The pre-hospital use of drugs and medication administration emerged in the mid 1970s. At the same time, the TV show “Emergency” with Roy and Johnny put EMS into every living room and, while it brought the profession to the public in an entertaining way, it also raised lasting expectations of what a paramedic could and would do.
The history of EMS services in Maine followed this same course. Most did start with a funeral service. Some were started by entrepreneurs who thought they could do it better, faster, or cheaper. However, most services lasted only a handful of years before being bought out or taken over. As many EMTs will attest, it is not the business to be in if you are in it for the money!
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NorthStar owes a debt to the five predecessor services that came together to form NorthStar. Their history, and NorthStar’s, is described below.
LifeStar, located in Farmington, was formed prior to 1974 by what was then known as Franklin County Hospital in association with Adams Funeral Home. This service then changed hands many times over the next several years. It was taken over by Able Funeral Home in 1974. Hawthorne absorbed Able in 1976. Hawthorne’s daughter married Frank Keegan, and Mr. Keegan took over the business in 1979. Upon Keegan’s bankruptcy in 1987, Delta Ambulance began running the service and continued to do so until October 1995, when Franklin Memorial Hospital (FMH) acquired the service and renamed it LifeStar. (It was also briefly known as FMH-EMS between 2002 and 2005.) Now as a part of the NorthStar system, it is the busiest base and handles all the interfacility transfers out of FMH. It is known as NorthStar’s Farmington Base.
Sugarloaf Ambulance and Rescue was formed in the Summer of 1971 by Ron Morin, one of the first licensed paramedics in the state. The service was actually started by the town of Carrabassett Valley to support the Sugarloaf Ski Resort in the late 1960s. Ron ran the service for the town during this period, formally taking ownership in 1971. Branching into other endeavors, Ron sold the service in 1993 to Pete Boucher. The service became a 24/7 job for Pete personally as the ambulance was often parked in his driveway ready for response. Faced with decreasing revenues and rising expenses, Pete sold the service to FMH in August 1996. Now known as the NorthStar/Sugarloaf Base. This base is the only NorthStar base to be named after a region, not the town in which it is located. Serving the long and rugged Route 27 wilderness corridor up to the Canadian border as well as Sugarloaf Ski Resort, it responds to some of the most serious trauma cases in the system. Auto vs. moose accidents and backcountry rescues of hikers, snowmobilers, ATVers, skiers and are routine for this base’s crews.
Rangeley Region Ambulance was one of the oldest services in the area. As early as the late 1950s and early 1960s, Olin Rowe, Rangeley’s long time Town Manager and Mortuary owner, provided emergency transports in his hearses with a red light on top. When Olin retired in the mid-1960s both the funeral business and the “ambulance” business was taken over by Maurice Thibeault. In 1968, one of the first recorded subsidy request was made to the town for $3,000. Early in 1969, long time Rangeley resident, Harlan Doak, then the town’s Fire Commissioner, along with a core of firefighters, began the first aid training necessary to form a true ambulance service. With Ron Morin, another early EMS pioneer, they became “Harvard grads” by attending an EMT class there in 1969. With his firefighters, Doak went on to take 8 hours of standard and another 8 hours of advanced first aid to qualify to be EMTs in the state. In March 1970, Rangeley Region Ambulance became an official town department. The first call was for a broken femur. With no traction equipment, a bystander was “recruited” to hold the leg for the entire trip to Farmington. Both patient and bystander survived. Each call thereafter was a learning experience. Lloyd “Pappy” Drinkwater taught classes on extrication and trauma care in 1971, Matt Powers, Paul Meservey and Farnham Folsom taught the use of the “portapower” extrication tool. Equipment was collected as it was needed and often right after it was needed. Putting straps on the stretchers, for example, is common sense today but was a new idea at the time. One of the early calls was an airplane crash. The pilot, in tux and patent leather shoes walked out of the woods to report the crash. The response became one of the first helicopter transports as a utility chopper was recruited to transport two of the three patients.
Through donations and town subsidies, the Ambulance service maintained two ambulances and built a solid reputation in the town. In June 1997, Dennis Mercer left as head of the service. Upon his departure, with no successor, the town’s Selectmen attempted to run the day to day ambulance service. When that proved to be contentious, discussions with FMH began in May 1998. By October 1998 local newspaper The Rangeley Highlander used the terms “the town’s embattled ambulance service” and the “bitter battle being fought over the organization of the service itself” to describe the situation. Nevertheless, in July 1999, the deal was set and FMH acquired the service and one of the ambulances, leasing the second ambulance and equipment from the town. It was not until NorthStar was formed in 2005 that the second ambulance and equipment was formally purchased from the Town.
Continuing to professionally serve the 24 towns and unorganized territories of the northwest part of the NorthStar coverage area, the station is now known as the NorthStar/Rangeley Base.
Community Emergency Service (CES) was formed in 1979 by a group of concerned community members as a private not-for-profit ambulance service to serve the three towns of Livermore, Livermore Falls and Jay.
In the late 1960s and early 1970s, EMS pioneer and early Paramedic Ron Morin and Bob LeClair started the Area Ambulance Service. This service was somewhat unique in the area at the time since it did not have a mortuary foundation. By the mid 1970s however, George O’Donnell, a local undertaker in Livermore Falls, had taken over the ambulance service responsibilities. After a series of responsiveness, care and training issues that included a service member who refused to do CPR, unreliable drivers, and a patient that fell out of the back of the ambulance, the local citizens decided to take matters into their own hands.
CES served the area with distinction under the early leadership of Gary Knight (whose license number 00700 earned him the “double-0-7” nickname), Mike Luciano, Larry and Shirley Heald and Tom Brackett. By 1987 they had purchased land and an old garage for a base in Livermore. In 1997, a new house for the base was built for the sum of $90,000.
In 1998, as the subsidy rose to $6.50 per capita, FMH was approached by a few board officers, including then President, Mary Dean, and asked the hospital to consider purchasing the system. FMH made a tentative offer to acquire the service but was rebuffed by the Board as a whole. The Treasurer, Norm St. Pierre, then resigned. LifeStar, now a part of FMH, then planned to put an ambulance in North Jay. CES responded by beginning discussions with United, a neighboring EMS service. The three Town Managers started questioning the subsidy. Volunteers (who were paid by the trip: $10 to FMH, $20 to Lewiston, $40 to Portland) were fading away. Tom Brackett left the service in the late 1990s and Tom Doak assumed leadership.
Finally, the CES directors had had enough and sold the service to FMH on June 30, 2000 for the sum of $286,750. That grand total included two ambulances, one base and equipment and a new monitor. While CES’s subscription program ceased with the hospital acquisition, the service’s long time staff members continue to provide excellent care to the residents of the three towns.
The station is now known as the NorthStar/Livermore Base and anchors the southern part of NorthStar’s coverage area.
AMPS was jointly formed as a non-profit corporation by the towns of Avon, Madrid, Phillips and Strong in the Fall of 1970. Dr. Greta Hoch, the towns’ health officer, prominent doctor, and resident of Phillips, led the effort shortly after a citizen of the town died of a heart attack during the big fire that destroyed downtown Phillips that year. Prior to that time, Donald James’s funeral home provided the locals with just the bare essentials of emergency transportation to the hospital. The early years of AMPS was characterized by the strong volunteerism credo that carried it for 30 years. Early volunteers and staff included Mary Piekart, Mike Ellis, Laura Toothaker, Don Schattschneider, Conley Gould, names well known to the area. Even in the latter years when Dr. Hoch pushed for paid staff, many refused the paycheck.
Seeking a guaranteed full-time paramedic response, Strong left the AMPS family in the latter 1990s to receive services from LifeStar. While not an official part of the corporation, the locals claim that the AMPS coverage in Salem continued to support the “S” in AMPS.
By the late 1990s, as was happening throughout the state, towns were seeking paramedic coverage and volunteers were fading away as jobs moved and training requirements became more intense. Wages, equipment and training put tremendous financial pressure on the small independent services that were unable to make up the revenue with the relative few transports. Facing rising costs, AMPS finally ceded the service to FMH in August 2000 becoming the fifth and final service in the area to do so. The proceeds were placed with a newly formed non-profit organization, Sandy River Ambulance Association (SRAA), with the goal of using the funds to continue to support the ambulance service. Over the years since 2000, SRAA has significantly contributed training funds, made equipment purchases and, for a time, coordinated volunteers and nighttime on-call staff.
The station is now known as the NorthStar/Phillips Base and, because of its central location in the region, plays a key supporting role throughout the system. It has also become an incubator for up-and-coming new EMS talent as an Americorp site and because of its good mentoring staff.
Thus for between 5 and 10 years, from 1995 to 2005, FMH ran five separately licensed, quasi-independent ambulance services. Various attempts during this time period were made to consolidate, but for a combination of political, financial or cultural reasons, the services were never brought together. Throughout this period, each service and its local service area was represented by a steering or advisory committee known as the Emergency Medical Service Advisory Boards. The services and their boards rarely interacted with one another.
Much of the resistance to consolidation was a result of incorrect or misleading perceptions in the communities (and bases). Varying and conflicting messages came from different leadership at different times at FMH and from within each of the services as they reported to “their” towns also contributed to the lack of desire to consolidate into a regional entity. Moreover, there was no clear dissemination of financials from the hospital, nor was there a clear comprehensive strategic plan for moving forward. Several consolidation “trial balloons” were floated but none that gained any traction in either the towns or with the advisory boards.
It was thought at the time that the culture of the “big city” bases of Farmington and Livermore could not be blended with the more laid back, very rural atmosphere of the northern bases. In fact, in the years before NorthStar, the entire coverage area was split between the Northern Tier (Rangeley, Sugarloaf, Phillips) and the Southern Tier (Farmington, Livermore). While this cultural difference was, and is, real and should not be taken lightly, it has proven to not significantly hinder the day to day operations of the services.
One contentious issue was financial. With their number of runs and shorter travel distances, the Southern Tier bases were, on paper, making a profit. The Northern Tier bases, on the other hand, while needing to staff for 24/7 coverage to assure response times over an extended geography, actually had few calls to generate revenue and were operating at a “loss”. Since the formula for the subsidies from the towns were specific to the bases serving those towns, the Southern Tier did not want to “cross subsidize” the Northern Tier towns. In reality, the bases frequently crossed their territorial town boundaries to support other bases and to handle transfers out of FMH so the “profit and loss” picture for each base was not as straight forward as many thought.
From a political standpoint, the towns focused on coverage from “their” local base and did not want change in personnel or license level. The staff members themselves were resistant to moving between bases and were reluctant to get out of their comfort zone of the territories with which they were familiar.
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The Gestation Period
By mid-2004, it was clear that maintaining five independent services was not cost effective for a small community hospital. The favorable Medicare reimbursement for hospital-based ambulance services was phasing out; meanwhile wages were increasing, equipment was aging, and morale was low.
The Board of Franklin Memorial Hospital and its parent organization, Franklin Community Health Network (FCHN) began pressuring leadership to either consolidate or divest the services. Given the community exposure and similar cachement area, one more attempt to consolidate - or, more accurately, to “regionalize” - the ambulance service was made. Key leadership at the hospital worked through the fall of 2004 reviewing options and working with the Boards, ambulance management and industry consultants. Gradually, a new plan came together.
In December of that year, at a meeting of services’ Advisory Board members, local town officials, and EMS staff, Franklin Memorial Hospital leadership outlined the details of a proposal to restructure the ambulance services that serve the region.
“We will implement a plan that will offer outstanding services in a more cost efficient arrangement,” said Richard Batt, FMH President “We will have a single regional program with one name, one set of policies and procedures, one governance structure, and one type of contract with area towns.” Batt explained that, in the current environment, small and independent rural EMS services were no longer viable. The case was made for regionalizing the five EMS service in order to protect the quality of service. “NorthStar,” Batt proclaimed, “will achieve economies that will allow us to continue to provide municipalities and patients with a high quality service.”
At the same time, he introduced David Robie as the new Director of NorthStar. Robie’s experience as an executive with St. Mary’s Regional Medical Center in Lewiston and his background in operations and finance made him the ideal candidate to lead this organization. Historically, the ambulance leadership – primarily former or current paramedics - had been strong in clinical expertise and great in patient care, but not as proficient in the “business of running a business.” Often the paramedic leadership would be diverted to “working a truck” at the cost of “working the office”. Although Robie lacked background in EMS, it was felt that Robie’s experience in medical environments would allow him to quickly understand the clinical aspects of the job, an assumption that has proved to be true.
Batt and Robie both praised the work of the EMS staff. Batt said, “Franklin Memorial Hospital has sponsored local EMS services for eleven years. During this time local EMS services have dramatically improved. We have an exceptional staff, among the best in New England. These changes will allow us to continue an outstanding quality service into the future.”
This historical meeting in late 2004 introduced a single contract and various key elements that would be in the regionalized, single service. The changes as they were identified and articulated by Batt in that 2004 proposal are listed below.
“The five separate ambulance services will be consolidated into one single regional program.”
“The new EMS service will be called NorthStar. Its new logo will be featured on all EMS vehicles, along with a listing of the five original services that combined to form NorthStar.”
“NorthStar will maintain ambulance sites throughout the region to respond quickly to emergency calls.”
“Paramedic level services will be continued.”
“NorthStar will implement cost efficiencies to reduce the financial commitments needed from towns and protect paramedic and EMT services, including shifting some staffing to times and locations when runs and needs are the greatest.”
“The hospital will assume the risk of any financial loss during the balance of the then contract period (ending June 30, 2005). Thereafter NorthStar stands on its own financially”
“A single NorthStar EMS Advisory Board will be formed to advise the FMH Board of Directors about EMS policy and financial issues.”
“There will be no layoffs of any EMS staff.”
“EMS staff will support additional community service activities when not engaged in emergency patient transport.” The NorthStar program has achieved each and every one of these goals.
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The Birth Process
Town government in many rural Maine communities is marked by an annual town meeting. Through this format, all financial and other major town matters are brought to the citizens at an open meeting, usually held in the spring of each year. Towns are rightfully proud in this tradition, and usually very town-centered in their decisions. This created a challenge for the case for regionalization of local ambulance services and creation of NorthStar, as it required town members to consider what was best for the surrounding towns and region as a whole, not just their own town.
At town meeting after town meeting, Robie and Batt and the ambulance leadership presented their case. Many questions were asked and answered, many towns took a deep breath and voted affirmatively for the new single service. The process was anything but easy. Letters of clarification regarding issues such as quality, paramedic coverage, cost, board representation, contract provisions and license levels passed between the FMH leadership and town officials. There was even a remarkable letter to the editor signed by ten of the LifeStar EMTs questioning the proposal, which expressed concern that paramedic coverage might not continue, response times might increase, jobs might be lost. None of these issues raised has proved to be a concern.
At each stage of the development, FCHN and NorthStar leadership listened closely to the concerns expressed by committees, by individuals, by selectmen, and by staff. The plan was adjusted wherever possible (such as continuing to staff the Phillips Base) and then again cycled through the review process to reach the collaboration and consensus to make the regionalization effort successful. This top-down-bottom-up approach of sharing information and involving the stakeholders and constituents greatly contributed to the future success of the program.
One by one, throughout the spring and early summer of 2005, each of the towns and municipalities approved the proposed plan by voting for and signing identical two-year contracts. The hospital formally implemented the new plan on July 1.
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The Early Months
One of the first orders of business for the new NorthStar was to establish a clear identity yet one that built on the history and heritage of the five predecessor services and on its affiliation with FMH. Using input from staff, a Mission Statement was developed, which has guided NorthStar ever since:
"The professionals of NorthStar will adhere to the highest standards of respectful patient care, engage in positive community activities, and exercise good stewardship of our resources, all in the pursuit of excellence."
A new logo was designed. A new paint scheme was created for the ambulances. Uniforms were designed and redesigned. A monthly newsletter (The Central Line) was started, which continues to be regularly published two years later.
Many challenges still faced the emerging EMS service. In the face of all these changes, staff morale sank even lower before eventually rebounding with a return to stability and compelling evidence of an improving service. Initially the fear of change and the unknown future of this new director and service were evident in the staff, in the towns and in the state.
NorthStar also faced challenges as it sought a single, regional license from the state. Historically, Maine EMS licenses EMS services by “base.” Only one other service in Maine had a single license for multiple bases and that one covered just two bases located in adjacent towns. Licensing five bases in widely dispersed towns over a large region was a significant change for the State. However, despite the anticipated obstacles, the State‘s process for obtaining a waiver for licensure worked well. After several conferences with the State, NorthStar’s waiver application was approved and a single region-wide license was granted. Since then, NorthStar has become a model for other multiple-base regional services to obtain licensure from the State.
Early in the process a top-to-bottom review was done of the equipment and vehicles. As a single system, NorthStar wanted to assure that every ambulance in the system was stocked and equipped similarly so that crews rotating around the system would always know where to find what they needed. And the vehicles themselves needed to be reliable, so NorthStar embarked upon a five- year systematic replacement of the aging fleet. By 2009, NorthStar will have completed this task, and will have completely turned over its fleet.
With a significantly larger crew spread over a large geographic area, NorthStar had to develop a way to communicate to a staff audience that was at the base only intermittently, had several other jobs, and often had no use for “home office” communications. Robie developed a web site (www.fchn.org/NorthStar) which is updated almost daily. This resource has become the focus for staff that want to know the latest news or information. Of course, emails, memos, crew meetings, committees, one-on-ones are also part of the communication package. The web site includes a Director’s Update page, training and events, a Members Page, Committee agendas and minutes and Community Information sections, and a Praises section which highlights of all the nice comments from patients and families, The entire website’s information is available for NorthStar staff and members of the community alike.
Another major goal was to establish a single subsidy formula that could be applied to all the towns and counties equitably. The towns served by NorthStar are extremely diverse. There many towns in the NorthStar service area, and none are very big (the largest, Farmington, is 5,000 people). Some towns are very wealthy and some are very poor; some have large ratables while others have none; some are large geographically and others just a dot on the map; some communities are bunched close together while the populations in others are widely dispersed. Finding a single formula that would divide up the subsidy paid by each town to sustain NorthStar was a daunting task. In fact, the first contracts that were offered in 2005 had subsidy amounts based on regional formulas because a single formula could not be agreed upon at the time of the initial consolidation. Over the 15 month period of July 2005 to October 2006, through the work of the NorthStar Advisory Board and the staff, literally thousands of combinations were tried until a formula using a town’s specific population, housing units, residential valuation from the prior year, a distance factor, and a flat fee was established. Even that, however, required annual maximum increase/decrease limits so that certain towns would not change too drastically.
Through another round of annual town meetings, selectmen meetings and town budget meetings in the spring of 2007, the new single formula effective at contract renewal was rolled out to the each towns’ citizenry. The rollout was successful. The full disclosure of NorthStar’s financials along with a reaffirmation that the goals set two years prior matched the results today added to the credibility that NorthStar was already building with its excellent patient care and community service.
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NorthStar Today (Still in its Youth)
What has NorthStar been up to lately? Something new all the time. Highlights from the first two years:
NorthStar continues to offer new and improved services to the community. In 2006, NorthStar began offering Lifeline services, a personal alert button system, to the community as a natural extension of its other emergency services. NorthStar has also implemented a house call program, which involves scheduled visits to shut-ins to do home safety checks, chronic disease monitoring, and simply keep in touch with community members as needed. NorthStar uses technology to provide high quality emergency care. Since NorthStar was created, it has put Global Positioning System (GPS) equipment in every vehicle, added computer based video conferencing capabilities to all bases, installed cell phone boosters in all vehicles to assure communications throughout the region, and purchased Stryker’s hydraulic/electric “Power Cots” for transporting bariatric patients and avoiding back injuries.
NorthStar’s staff continues to strive for professional excellence. The last few years have seen several license level promotions for staff who have moved from basic to intermediate to paramedic. This progression is assisted by tuition support from NorthStar and FMH. Virtually all of the staff is National Incident Management System (NIMS) IS-700 certified, with most certified at higher levels as well. And, appropriately for this region, NorthStar boasts the highest ratio of Wilderness EMTs in Maine. NorthStar’s Backcountry Medical Response Team responds to wilderness rescues throughout the region.
NorthStar has been honored with several awards, including designation as a HeartSafe Community EMS Service at the Gold level in May 2007. NorthStar also has a Four-Star Avatar rating for patient satisfaction. As first in the state to formulate an EMS Pandemic Flu response plan, NorthStar has proven to be a leader in pandemic preparedness, and has participated in several local and regional and state disaster drills and conferences on pandemic flu. NorthStar was the first in the state to implement the State’s electronic run report system.
In 2007, NorthStar became one of only ten Maine services qualified to have a paramedic authorize the opening of a catherization lab based on the pre-hospital evaluation of a patient.
As importantly, however, NorthStar continues to exert a prominent and respected force in the community. Crews average over 3,000 community service and special project hours per year. This includes staffing the First Aid Booth at the county’s huge agricultural “Farmington Fair,” holding mock OUI crash scene reenactments for local high schools, holding frequent school and senior citizen education programs, and participating in myriad athletic events, festivals and fairs. Remaining visible in the community continues to be a focus for NorthStar in the years to come.
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What’s next?
It is hard to predict the future in this business. Looking forward, NorthStar will continue to improve its standing in the communities it serves through its commitment to community service, respectful patient care, and constantly improving equipment, training, and ensuring that staff and every patient and family are properly treated and cared for.
Innovative, state of the art, progressive. Ready, reliable, responsive. An outstanding service for its community … and getting better all the time.
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NorthStar: Building on the Past. Performing in the Present. Preparing for the Future.
