By Sally Buck, CEO
It is an exciting time for the Medicare Rural Hospital Flexibility (Flex) Program state grantees and partners as we recognize the program has reached its sweet 16, which is to say 16 years in existence. The Flex program was born as part of the Balanced Budget Act of 1997 to provide funding to states for the designation of critical access hospitals (CAHs) in rural communities and allows hospitals to be reimbursed on a reasonable cost basis for inpatient and outpatient services provided to Medicare patients. There are now 1,326 CAHs in the Flex program that play an essential role in sustaining rural health care.
The National Rural Health Resource Center (The Center) has the pride of a parent seeing their “child” reach this milestone of 16 years. Terry Hill, former Executive Director of The Center, was involved in the initial development of the Flex Program with the Federal Office of Rural Health Policy (FORHP) to support small rural hospitals in the conversions, development of networks, quality improvement and financial stabilization. Through a contract, The Center established an innovative technical assistance model: Technical Assistance and Services Center (TASC) in 1998 to provide information and education about Flex to the state grantees and their partners.
In the infancy, TASC supported the states with development of rural health plans and creating “any necessary provider” rules, financial feasibility tools for assessing conversions. Through the toddler years, TASC provided state Flex grantees with education on cost reports, establishing networks for care transitions and quality improvement. It’s hard to imagine, but when we started, we didn’t have webinar technology, and the webpages were often static pages without search functions.
By the 10 year mark, the Flex program had moved into CAHs with swing beds to accommodate post acute care services. The “any necessary provider” rules reached their sunset, and conversions to CAH status dramatically declined. Flex programs and TASC mobilized to support CAHs to trauma designations through emergency medical services (EMS) and CAH training and regional planning. With a decade of experience, TASC, the Flex Monitoring Team (FMT) and state Flex programs worked together to provide CAHs with more data about the financial, quality and community engagement status within their state and nationally. Hospital Compare was launched by the Centers for Medicare & Medicaid Services (CMS), and although CAHs weren’t required to report quality, hundreds of performance indicators became more important for all hospitals.
As the Flex program reached the awkward stage of the teenage years, the grantees adapted to new reporting requirements, and outcome-focused work plans. CAHs were watching the transformation of health care payment models evolve without a small volume option. A new initiative, the Medicare Beneficiary Quality Improvement Program (MBQIP) was introduced by FORHP in 2010 to increase quality reporting by CAHs with rural relevant measures and data to spur quality improvement efforts. This was a critical activity as CAHs were experiencing some bullying about their performance. With MBQIP, the Flex program has dramatically increased quality reporting by CAHs and states have implemented a number of initiatives to improve patient safety, satisfaction and patient outcomes.
Now at 16 years of age, Flex is developing a vision of what it will become in the future as a mature program and what impact Flex, with over 1,300 CAHs, will have on rural health care in the U.S. and the thousands of communities served. With the changes in health care delivery and payment, the Flex Program needs to continue to share best practices, learn from peers and experts to ensure small rural hospitals can continue to improve care and the health of rural communities and reduce costs. Happy Sweet 16 to the Flex Program, and best wishes for many more successful years to come!
The Rural Hospital Flexibility (Flex) Program was started in 1997. A federal initiative, it was created by the Balanced Budget Act and is credited with launching the Critical Access Hospital (CAH) program. The Flex program works to support and strengthen rural health care systems by awarding grants to state governments that can be used for such things as promoting community engagement, supporting financial and operational improvements in CAHs, or integrating EMS in regional and local health care systems.
Sara Roberts, Director of the Kansas State Office of Rural Health (SORH), and John Packham, Director of Health Policy Research in Nevada’s SORH co-chair the NOSORH Flex Committee. One of the primary functions of the committee is to help states prepare for competitive grants and assist them in managing the Flex grant once it is awarded. “What we do is provide support and assistance for the Critical Access Hospitals,” Roberts said. “That includes helping states design programs to manage their Flex grant.”
Additionally, the Flex Committee serves as a link for the Flex Coordinators in the state offices. “Every month we have anywhere from 20 to 40 people on our committee call sharing information and ideas between states.It’s a great committee call because we have Flex Coordinators, national partners and SORH guests on the line at the same time brainstorming ideas,” Roberts said.
Looking ahead, co-chair Packham is confident the Flex Committee will continue to be a valuable resource in the advancement of rural health care. “The NOSORH Flex Committee will continue to provide an important forum for Flex Coordinators to exchange ideas on what is and is not working to implement Flex-supported activities in their states,” he said. As well as “provide an opportunity for new Flex Coordinators to learn from veteran Flex Coordinators and SORHs from across the country.”
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A project sponsored by the Massachusetts State Office of Rural Health (MA SORH) is helping rural hospitals in the state learn how to reduce the possibility of medication-related patient harm. With the Medication Safety Performance Improvement Project, the MA SORH has contracted with the Institute for Safe Medication Practices (ISMP) to perform one-day targeted medication safety risk assessments at the hospitals.
ISMP recently started offering these one-day medication safety assessments with small and rural hospitals in mind. Each hospital assessment visit focuses on one or two predetermined, mutually agreed upon topic areas in medication safety such as sterile compounding, oncology, medication use in the perioperative areas, or medication administration practices. The ISMP team meets with and interviews key hospital administrators, medical and clinical staff, and other hospital managers to gain an understanding of current medication use practices in the areas of focus. Although the hospital pharmacist takes the lead, it’s important that other hospital staff is included since they all have a role in medication safety, said Cathleen McElligott, director of the Massachusetts State Office of Rural Health.
At the conclusion of the visit, the ISMP team presents their findings through an interactive presentation. The focus of the presentation is to identify areas of risk exposure observed within the designated areas of focus and to make prioritized recommendations for change. Following the visit, ISMP creates a written report that describes specific medication safety recommendations and provides associated references and tools to assist with implementation of the safety strategies.
The project, which began in April of last year, has been piloted with four hospitals in the state. “It’s been so successful that we’re adding four more hospitals this spring,” McElligott said.
According to Ronnie Rom, MA Flex Coordinator, who began and now coordinates the pharmacy project, the facilities that have participated have noted significant improvements in medication storage, labeling, removal and verification processes. The project has also been a contributing factor to achieving 24/7 coverage sign-off at a couple of the facilities, Rom said. Participants have lauded the ISMP team for having “engaged hospital employees across disciplines and committees,” and for offering “concrete guidance to improve evaluation/measurement of patient safety.” In addition, Rom said, participants have shared that they have found it “especially helpful to have this opportunity be presented by the SORH as a healthy non-judgmental check-up vs. a problem-initiated visit.”
The New England Rural Health Roundtable provides reimbursement for the project with funds provided by the MA SORH’s Rural Hospital Flexibility Program. “We found the ISMP team highly professional and easy to work with,” Rom said. “We think other flex programs should take advantage of this,” McElligott added.
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