PROGRAM AREAS OF THE FLEX PROGRAM. Every Patient Matters

PROGRAM AREAS OF THE FLEX PROGRAM Every Patient Matters In fiscal year (FY) 2015 (September 1, 2015 August 31, 2016), the Flex Prgram began a new prject perid fcused n funding activities that can prvide clear utcmes and demnstrated imprvements in the rapidly changing health care envirnment. The Flex Prgram, as a three-year prject perid, is designed t allw state Flex grantees t develp, implement and measure impact and imprvement within the key prgram areas f the grant. It is shrt enugh that, given the changing health care envirnment, the Federal Office f Rural Health Plicy (FORHP) can adapt the prgram t better align as needed fr the next grant cycle. FOHRP added a nn-cmpetitive cntinuatin year extensin fr the FY 2018 grant year. State Flex funding fr this prject perid will act as a resurce and fcal pint fr strategic planning in the fllwing prgram areas with an emphasis n quality and financial and peratinal imprvement: 1. Quality Imprvement (required) 2. Financial and Operatinal Imprvement (required) 3. Ppulatin Health Management and Emergency Medical Services (EMS) Integratin (ptinal) 4. Designatin f critical access hspitals (CAHs) in the State (required if requested by a hspital) 5. Integratin f Innvative Health Care Mdels (ptinal) The first tw prgram areas, Quality Imprvement and Financial and Operatinal Imprvement, are required t be addressed by all state Flex Prgrams. The third prgram area, Ppulatin Health Management and EMS Integratin, is ptinal. Hwever, Activity 3.01, Statewide Ppulatin Health Management Needs Assessment (see belw), is required if any ther activities within the third prgram area are selected. Designatin f CAHs in the State is required nly if hspitals in the applicant s state seek help in cnversin t CAH status. The fifth prgram area, Integratin f Innvative Health Care Mdels, is the newest element f the Flex Prgram designed t allw states t think creatively abut transfrming rural care acrss their state given gaps identified thrugh the applicatin develpment prcess, initial needs assessment cllectin and ther relevant data. The fifth prgram area is ptinal and allws fr states t design a mre innvative prject NATIONAL RURAL HEALTH RESOURCE CENTER 10

that des nt fit int ther prgram areas, if they have demnstrated that existing needs f CAHs in the tw required prgram areas have been addressed. Ultimately, the verall gals f the Flex Prgram are t: Imprve the quality f care prvided by CAHs Imprve the financial and peratinal utcmes f CAHs Understand the cmmunity health and EMS needs f CAHs Enhance the health f rural cmmunities thrugh cmmunity/ppulatin health imprvement Imprve identificatin and management f Time Critical Diagnses and enhance EMS capacity and perfrmance in rural cmmunities Supprt the financial and peratinal transitin t value-based mdels and health care transfrmatin mdels in the health care system While wrking n prgram activities, states are encuraged t wrk with: quality innvatin netwrks (QINs), state hspital assciatins, health infrmatin exchanges (HIEs), hspital imprvement innvatin netwrks (HIINs), state rural health assciatins and thers cncerned with the future f rural health care. I. Quality Imprvement This prgram area, referred t as the Medicare Beneficiary Quality Imprvement Prject (MBQIP), fcuses n wrk t imprve the quality f health care prvided by CAHs and ther rural health care prviders. Other types f health care prviders can and shuld benefit frm this wrk, but the majrity f activities must target CAHs. MBQIP activities are gruped in fur different quality dmains: Patient Safety/Inpatient, Patient Engagement, Care Transitins and Outpatient. FORHP expects all grantees t select Activities 1.01-1.04 (required) and 1.09 (required, if needed) which cvers the fur quality dmains f MBQIP. Building and maintaining the participatin f all CAHs in MBQIP thrugh these sets f quality measurement and reprting activities are required. In year ne f the grant cycle, it was acceptable t wrk twards building the capacity fr CAHs t participate in these activities and reprt data if they are nt already ding s. Fr CAHs already engaged in quality reprting, the fcus shuld be quality imprvement. T be eligible t benefit frm Flex grant funds in FY 2016 (September 1, 2016 August 31, 2017), CAHs had t have a signed MBQIP Memrandum f Understanding (MOU) n file with FORHP and have submitted MBQIP measure data n at least ne measure fr at least ne quarter in at least ne f the fur quality dmains within nted reprting perids, r have cmpleted the necessary MBQIP NATIONAL RURAL HEALTH RESOURCE CENTER 11

waiver. Fr FY 2017 (September 1, 2017 August 31, 2018) and FY 2018 (September 1, 2018 August 31, 2019), in additin t having a signed MOU n file, the CAH needs t submit MBQIP measure data fr at least ne quarter in at least tw f the fur quality dmains within nted reprting perids. FY 2019 (September 1, 2019 August 31, 2020) eligibility criteria is als available n the Flex Eligibility Criteria fr MBQIP Participatin and Waiver Templates page f the TASC website. Every year, FORHP evaluates increasing the MBQIP participatin requirements fr CAHs t be eligible t participate in the Flex Prgram and Flex-related activities. FORHP understands that certain circumstances hinder CAHs frm reprting. Therefre, Flex Prgrams have the pprtunity t request waivers fr MBQIP participatin requirements fr FY 2018 n behalf f CAHs initially deemed ineligible due t nn-participatin. The Flex Prgram must submit a waiver as part f their nn-cmpeting cntinuatin (NCC) prgress reprt as an attachment. Detailed participatin criteria are currently available frm FORHP cncerning participatin thrugh FY 2019. MBQIP eligibility infrmatin fr FY 2016 FY 2019 and a waiver template can be fund n the MBQIP participatin webpage. Alng with the required set f quality imprvement activities, there are additinal activities that grantees are encuraged t select based n the needs f the CAHs in their state (Activities 1.05 1.08). These activities d nt require participatin by all CAHs, but instead shuld include a chrt(s) f CAHs in the state prepared t fcus quality imprvement effrts n the identified area. It is acceptable t wrk with an individual hspital, but the need must be clearly justified. While sme f the additinal activities d have existing measures, sme d nt have a standardized measure set r reprting mechanism. These activities were included t give states an ptin t wrk n these natinal quality pririty areas. Ptential resurces related t quality imprvement include: MBQIP website Flex Mnitring Team (FMT) Emergency Department Transfer Cmmunicatin Gal 1: T imprve the quality f care prvided by CAHs Objective 1.1: Assist CAHs in implementing quality imprvement activities t imprve patient utcmes Activity 1.01 (Required): Imprve patient safety in CAHs and the cmmunity by ensuring all health care prviders and eligible patient ppulatins receive their influenza vaccinatins NATIONAL RURAL HEALTH RESOURCE CENTER 12

Activity 1.02 (Required): Imprve the patient experience f care thrugh use f the Hspital Cnsumer Assessment f Healthcare Prviders and Systems (HCAHPS) survey Activity 1.03 (Required): Imprve the transitins f care frm the CAH t ther health care settings in rder t imprve patient utcmes Activity 1.04 (Required): Imprve the care prvided in CAH utpatient settings in rder t imprve patient utcmes Activity 1.05 (Optinal): Imprve patient safety and health utcmes in CAHs thrugh ther measures. Specific areas f fcus may include: health care acquired infectins (HAI), strke care, venus thrmbemblism (VTE), pneumnia care, surgical care, perinatal care, falls, adverse drug events (ADE), reducing readmissins and patient safety culture survey Activity 1.06 (Optinal) Imprve care transitins frm CAHs t ther health care settings thrugh imprved Discharge Planning Activity 1.07 (Optinal) Imprve care transitins thrugh imprved Medicatin Recnciliatin activities Activity 1.08 (Optinal) Imprve the care prvided in CAH Outpatient and Emergency Department settings thrugh additinal measures Objective 1.2: Assist all CAHs in the state t cnsistently publicly reprt data n all required measures Grantees shuld wrk with CAHs t imprve the number f hspitals reprting n the required measures, including publicly reprting t the Centers fr Medicare & Medicaid Services (CMS) Hspital Cmpare. CAHs in need f assistance shuld be identified as part f the needs assessment prcess. Grantees may engage partners t prvide the necessary technical assistance (TA) arund quality reprting with a fcus n enhancing CAH capacity (at an rganizatinal level, nt nly individual staff level) t reprt quality measures. CAHs are expected t cllect and reprt quality data as a fundamental part f health care peratins. Peridic retraining n quality reprting is allwable if challenges are identified during the prject perid. Quality data must be reprted in rder t measure and evaluate the utcmes f quality imprvement activities cnducted under Objective 1.1 activities as well as t cnduct needs assessments fr determining quality imprvement fcus areas in subsequent years f the grant cycle. Activity 1.09 (Required, if needed) Prmte and imprve the reprting f quality f care data by CAHs NATIONAL RURAL HEALTH RESOURCE CENTER 13

II. Financial and Operatinal Imprvement FORHP expects all grantees t select Activity 2.01 and at least ne ther activity frm areas 2.02-2.04 every year. Certain measures and data reprting will be required based n the activity(s) selected. FORHP encurages states t identify new r existing successful financial and peratinal imprvement prgrams and leverage thse t meet the cllective needs f CAHs in yur state in rder t maximize the impact f limited Flex funds. States shuld minimize cnsultant expenditures tward individual CAHs fr imprvement activities and shuld instead fcus n chrts, unless adequately justified. Gal 2: T imprve the financial and peratinal utcmes f CAHs Objective 2.1: T identify financial and peratinal strengths and challenges and t identify statewide and targeted strategies fr imprvement Activity 2.01 (Required) Financial and Operatinal Assessment This is a required assessment f statewide CAH financial needs by Flex Crdinatrs using FMT data (23 indicatrs) r 10 indicatrs in the Small Rural Hspital and Clinic Finance 101 Manual and ther hspital financial data, if available in yur state. The majrity f this infrmatin shuld be n-hand and presented within the needs assessment sectin f the grant applicatin. Data frm CAH Financial Indicatr Reprts (CAHFIR) prduced by the Flex Mnitring Team shuld be included. Publicly available statelevel indicatr reprts, and ancillary resurces can be dwnladed frm FMT website. State Flex Crdinatrs access CAHFIRs fr the hspitals in their state frm the CAHMPAS. CAHMPAS is a web-based, lg-in prtected data query tl fr CAH executives, state Flex Crdinatrs and federal staff t explre the financial, quality and cmmunity-benefit perfrmance f CAHs. CAHMPAS prvides graphs and data, which allw cmparisn f CAH perfrmance fr varius measures acrss user defined grups: by lcatin, net patient revenue r ther factrs. The data included in CAHMPAS includes six years f data fr 23 financial indicatrs as well as peer grup, state and natinal cmparative data. Objective 2.2: T identify mre in-depth financial and peratinal strengths and prblems based n trends r issues identified thrugh Objective 2.01, and t identify majr strategies fr imprvement fr a hspital r chrt f hspitals Activity 2.02 (Optinal) Financial and Operatinal In-depth Assessment(s) and Actin Planning NATIONAL RURAL HEALTH RESOURCE CENTER 14

Fcus may include: alignment f services with cmmunity needs; preparatin fr new payment and care delivery mdels; service line analysis; analysis f department-level staffing; physician practice management assessments; r analysis f reprting practices fr Medicare reimbursement. Objective 2.3: T imprve revenue cycle management and t implement activities designed t increase prfitability within a hspital r grup f hspitals Activity 2.03 (Optinal) Revenue Cycle Management Fcus may include: cmprehensive chargemaster review; billing and cding educatin; implementatin f revenue cntrl prcess; financial imprvement netwrks; r educatin and training fr hspital persnnel and bards t imprve revenue management and prcesses. Objective 2.4: T address areas fr imprvement (within a hspital r grup f hspitals) identified thrugh in-depth peratinal assessments Operatinal imprvement activities may have several areas f fcus, including hspital departments, hspital services and hspital prcesses. This wrk can be dne thrugh Lean r ther prcess imprvement activities, wrkshps, direct cnsultatins t CAHs r financial imprvement netwrks. Operatinal imprvement activities may be needed within a hspital in rder t build and maintain capacity, t reprt quality data and effectively implement quality imprvement activities under MBQIP. Activity 2.04 (Optinal) Operatinal Imprvements Fcus may include: imprving peratins within hspital departments; enhancing a hspital s ability t meet the needs f the cmmunity by increasing hspital service fferings; r imprving peratins within hspital prcesses. III. Ppulatin Health Management and Emergency Medical Services Integratin This prgram area fcuses n wrk t imprve the health f rural cmmunities thrugh ppulatin health management; cmmunicatin and cllabratin between different health care prviders; imprving patient experiences when transitining frm ne care setting t anther; and building EMS capacity t best serve CAHs and their cmmunities. If state Flex grantees select any Activity 3.02-3.06, they must als select Activity 3.01 t infrm pririties fr ther activities funded. Grantees may undertake NATIONAL RURAL HEALTH RESOURCE CENTER 15

assessment wrk during the first year f the grant cycle with develpment and implementatin f targeted activities taking place during years tw and three. Prjects can be fr ne year r multiple years. At the end f each grant year, the grantee is expected t dcument significant prgress against a set target measure, but it is understd that many f these activities cannt be cmpleted in ne year. Fr example, an imprvement activity might be planned in year ne, cnducted in year tw and assessed in year three t determine if the activity was successful. N mre than ne quarter f ttal grant funds can be spent in this prgram area. Certain measures and data reprting will be required based n the activity(s) selected. Gal 3a: T understand the cmmunity health and EMS needs f CAHs Objective 3.1: Determine cllective issues and trends in ppulatin health management fr CAHs This assessment shuld examine the cllective issues and trends acrss yur state. It shuld include infrmatin frm the cmmunity health needs assessments (CHNAs) required fr all nt-fr-prfit hspitals as well as needs assessments frm fr-prfit hspitals when available. Activity 3.01 (Required in prject perid if this prgram area selected) Statewide CAH Ppulatin Health Management Needs Assessment Objective 3.2: T assist CAHs t identify specific health needs f their cmmunities and implement activities Activity 3.02 (Optinal) Hspital CHNAs and Imprvement These assessments and related prjects help specific hspitals r chrts f hspitals t identify specific health needs f their cmmunities and prgrams t identify ppulatin health imprvement activities, with a fcus n building capacity and sustainability. Prjects culd include: sharing f findings and best practices amng hspitals; prviding TA t hspitals t help them cnduct a CHNA; educatin n health preventin and prmtin strategies; and/r supprt fr develpment f reginal ppulatin health imprvement activities. Nte that state Flex grantees are nt allwed pay fr CHNAs t be cnducted at individual CAHs. Objective 3.03: Imprve lcal/reginal EMS capacity and perfrmance in CAH cmmunities. Imprve integratin f EMS in lcal/reginal systems f care Activity 3.03 (Optinal) Cmmunity-level Rural EMS System Assessment NATIONAL RURAL HEALTH RESOURCE CENTER 16

This activity shuld be dne using a standard assessment tl. Gal 3b: T enhance the health f rural cmmunities thrugh cmmunity/ppulatin health imprvement Objective 3.04: T assist CAHs t develp strategies fr engaging with cmmunity partners and targeting specific health needs Activity 3.04 (Optinal) Ppulatin Health Imprvement Activity Gal 3c: T imprve identificatin and management f Time Critical Diagnses and engage EMS capacity and perfrmance in rural cmmunities Objective 3.04: T assist CAHs t develp strategies fr engaging with cmmunity partners and targeting specific health needs Activity 3.05 (Optinal) Imprve Time Critical Diagnses EMS System Capacity This wrk shuld be fcused n cnditins like ST elevatin mycardial infarctin (STEMI), strke and trauma. Activity 3.06 (Optinal) Imprve EMS Capacity and Operatinal Prjects This wrk shuld include data frm the EMS assessment prcess (Activity 3.03) and ther surces. EMS capacity prjects culd include: develping cllabrative linkages t imprve lcal pre-hspital and emergency care capacity; imprving EMS agency capacity t cllect, reprt and use quality data fr perfrmance imprvement; r enhancing billing, cllectin and financial systems and ability t use financial data fr perfrmance imprvement. FY 2018 Flex EMS Sustainability Prjects Due t the Cnslidated Apprpriatins Act f 2018, the Flex Prgram received additinal funding, f which, $2 millin was allcated by FORHP t fund EMS prjects t supprt EMS sustainability. This funding is t be used fr prjects during the FY 2018 prject year (September 1, 2018 August 31, 2019). Gals include: T develp and implement sustainable mdels f rural EMS care T identify a set f rural-relevant EMS quality measures and prepare the fundatin t pilt test the measures States indicated their intent and applied t FORHP. The funds were divided amngst state Flex Prgrams with prjects that fell within the scpe f the funding. Fr mre backgrund infrmatin abut the FY 2018 EMS Sustainability prjects, please see the Flex Grant Guidance page n the TASC website. NATIONAL RURAL HEALTH RESOURCE CENTER 17

IV. Designatin f CAHs in the State In accrdance with current statute, state Flex Prgrams are expected t facilitate apprpriate cnversin f small rural hspitals t CAH status. Flex Prgrams must assist hspitals in evaluating the effects f cnversin t CAH status. This may include assisting with financial feasibility studies fr hspitals cnsidering cnversin t CAH status, as well as feasibility studies fr repening clsed rural hspitals r cnverting CAHs t ther types f facilities. V. Integratin f Innvative Health Care Mdels This ptinal prgram area fcuses n develping and integrating innvative health care mdels arund the areas f quality, financial/peratins, ppulatin health and/r system delivery in rural cmmunities. Ideally, successful mdels will imprve care in rural areas and serve as best practices r strategies fr ther states. Prgram Area five is fr state Flex grantees that have been able t meet the majrity f needs f CAHs within their state and have additinal capacity t take n an innvative prject that isn t captured in the ther Prgram Areas. These innvative prjects will be mnitred and used t infrm activities included in the next Flex grant prject perid cycle. Nte: Given the intensive nature f Patient Centered Medical Hme (PCMH) prjects, which fall utside f the scpe f the Flex grant, any PCMH activities cannt be included. Grantees may undertake assessment wrk during the first year f the grant cycle with develpment and implementatin f targeted activities taking place during subsequent years f the grant cycle. Prjects can be fr ne year r multiple years. At the end f each grant year, the grantee is expected t dcument significant prgress against a set target measure, but it is understd that many f these activities cannt be cmpleted in ne year. Fr example, an imprvement activity might be planned in year ne, cnducted in year tw and assessed in year three t determine if the activity was successful. Prjects prpsed must include clear methdlgy and clear and measurable utcmes. Gal 5: T supprt the financial and peratinal transitin t valuebased mdels and health care transfrmatin mdels in the health care system Flex funds can be used t assess the impact r supprt the implementatin f health care system changes that will have a substantial effect n quality, financial and peratinal perfrmance, ppulatin health management r EMS integratin f CAHs. A prject in this categry must include prpsed bjectives, activities and desired utcmes. NATIONAL RURAL HEALTH RESOURCE CENTER 18

Objective 5.01: T develp/implement and assess innvative health care mdels designed t have a psitive transfrmatinal impact n rural health Activity 5.01 Integratin f Innvative Health Care Mdels Specific areas f fcus may include: clinically integrated netwrks; ppulatin health management; prjects addressing frequent/high cst users f health care r emergency department; r care crdinatin. NATIONAL RURAL HEALTH RESOURCE CENTER 19