EMS in Madison County is a community of contrasts, with pockets of urban communities adjacent to large rural landscapes. This diversity is reflected in the many different types of organizations providing ambulance service. Many services were established by dedicated residents reacting to a community needby donating vehicles and garages to establish a local ambulance service. EMS volunteers spent hundreds of hours traveling to Syracuse or Utica to obtain initial training as caregivers. Fitch and Associates (FITCH) was engaged to conduct an Emergency Medical Service Study for the county. The effort was undertaken with the region’s pre-hospital care community to conduct a comprehensive, thorough and objective review of the emergency medical services system. The County requested FITCHprovide three options to improve service and enhance program sustainability, quality, efficiency and affordability.