Resources: Critical Access Hospitals

Determining whether CAH conversion is advisable is both a hospital and community decision. A financial feasibility assessment is the first step in making an informed decision; additional considerations are community need and administrative effect on hospital operations. State Flex Programs spend considerable resources on conversion activities including communication and technical assistance, building coalitions, and troubleshooting.

             Tools Resources Organizations

Tools

CAH Financial Performance Indicators
Organization: Flex Monitoring Team
As part of ongoing work of the Flex Monitoring Team, twenty financial indicators were specifically designed to capture the financial performance of CAHs. The creation of these indicators are based on three criteria: feasibility (whether the indicator can be accurately calculated from Medicare cost report data), importance (whether the indicator is an important measure of the financial management of CAHs), and usefulness (whether the indicator is useful to CAH administrators). The state graphs listed in the drop down box below present the 2005 financial indicator values of each CAH in that state. Individual hospitals are not identified. Each of the twenty indicators has its own graph and also includes the national and state median for comparison.

CAH Physician Survey
This is an example of a survey of physicians at CAHS. The document is from the Michigan Center for Rural Health.

Critical Access Hospital Prototype
Author(s): Health Resources and Services Administration
BBH Design, Research Triangle Park North Carolina received an architectural-engineering services contract from the Division of Engineering Services, Health Resources and Services Administration, Department of Health and Human Services and the Office of Rural Health Policy to develop two alternative prototype designs for 25 and 15 bed Critical Access Hospitals. The intent of the prototype is to provide guiding principles to assist the hospital in development of a replacement facility. The schematic designs will permit the hospital to add or subtract from the designs based on their specific needs.

CAH Program; Decision Flowchart
This flowchart, prepared by the Washington State Department of Health, Office of Rural Health, is a visual description of the decision making process for CAH designation.

CAH Program Technical Assistance Grants Fact Sheet
The document, prepared by the Colorado Rural Health Center, gives information about the process of applying for CAH grants in Colorado and can be adapted for use by any state.

Checklist for Medicare Critical Access Hospital (CAH) Certification Survey
The checklist, from the Nevada Center for Education and Health, is designed for use by hospital administrators and staff to ensure that they are prepared for the initial survey their hospital will undergo as part of the CAH application process.

Conducting Hospital Employee Feedback Surveys - Training Module
Developed by Linda Powell of Mountain States Group, this module a list of those tools and examples for employee feedback surveys as well as other tools that you can download in their original format so you can edit and use what you need. Simply click on the file you want to download.

Current Status of CAH Components
This document from the Michigan Center for Rural Health is an example of a grid that could be used to track data and services of CAHs.

"Necessary Provider" Definitions
This document is a compilation of State's criteria for designation as a necessary provider that shows how each state has addressed local considerations or unique requirements.

Patient Satisfaction Surveys for Critical Access Hospitals
This manual provides information on survey methods and how to conduct a patient satisfaction survey. Patient satisfaction survey and report templates are also included. Published by Linda Powell, Mountain States Group.

Sample Network Agreement
This agreement, developed by the Nebraska Hospital Association, covers patient referrals and transfers, transportation, communication systems, credentialing and quality assurance.

Starting a Rural Health Clinic - A How-To Manual
The purpose of this book is to walk the reader through the steps that are required to become a Federally-certified Rural Health Clinic and complete the necessary financial audit to determine the clinic¿s per visit rate. If you are looking for a way to stabilize the availability of primary care services or make primary care services available in a community that has had difficulty recruiting or retaining primary care health professionals, then we encourage you to learn more about the advantages of operating your practice or clinic as a Federally-certified Rural Health Clinic.

Strategic Planning Module
Developed by Linda Powell of Mountain States Group, the Strategic Planning Module contains a list of those tools and examples as well as other tools that you can download in their original format so you can edit and use what you need. Simply click on the file you want to download.

Swing Bed Policy and Procedures
This document, developed by the Illinois Department of Public Health, Center for Rural Health, lists the policies and procedures that are suggested for the Swing Bed facility in a CAH.

Survey Tools

Transforming Hospitals: Designing for Safety and Quality
Can the design of a hospital affect the quality of your care? Does noise reduction improve patient satisfaction? Will better lighting decrease medical errors? The evidence says yes. HHS. Agency for Healthcare Research and Quality has just released a new DVD that provides evidence to help hospital officials and architects design safer, high quality hospitals. This new two-part DVD illustrates the value of evidence-based hospital design . a phrase used to describe how the physical design of health care environments affects patients and staff.

Resources

CAH Fact Sheet
This document, from the Centers for Medicare and Medicaid Services (CMS), provides further clarification on the implementation of the Medicare Modernization Act of 2003 guidelines for the Critical Access Hospital Program.

CAH Financial Indicators Report: Summary of Indicator Medians by State
This Briefing Paper presents state and national median values of the twenty financial indicators included in the 'CAH Financial Indicators Report'. These indicators were specifically designed to capture the financial performance of CAHs.

CAH Status Report
This Microsoft Excel template was developed by the Center for Rural Health, School of Medicine, University of North Dakota. It is used to track the progress of hospitals that are working on CAH certification so that status can be seen at a glance, from a single page.

CAH Talking Points for Physicians
This document, prepared by the Illinois Department of Public Health, Center for rural Health, lists benefits, requirements, and expectations of critical access hospitals.

CMS Critical Access Hospital (CAH) Claims
This Special Edition article was issued based on instructions from CMS. Providers submitting claims to Medicare fiscal intermediaries for CAH anesthesia and ambulance services are effected by this change.

The Community Benefit and Impact of Critical Access Hospitals: The Results of the 2007 CAH Survey (March 2008)
In 2007, the Flex Monitoring Team conducted a national telephone survey of 381 critical access hospital administrators covering a wide variety of questions concerning hospitals' community benefit and impact activities. This Briefing Paper reports on the community benefit and impact findings of this survey.

Critical Access Hospitals' Experiences with Medicare Advantage Plans
Organization: NORC Walsh Center for Rural Health Analysis and RUPRI Center for Rural Health Policy Analysis
This report details findings from a survey of 60 critical access hospital (CAH) administrators regarding their experiences with Medicare Advantage (MA) plans. Findings from this research identify concerns of CAH administrators that, as the MA program evolves, may be addressed through technical assistance and changes in regulation or legislation.

Critical Access Hospital Frequently Asked Questions
This link to the Rural Assistance Center's website has a list of Frequently Asked Questions related to Critical Access Hospitals.

Critical Access Hospital Quality Improvement Activities and Reporting on Quality Measures: Results of the 2007 National CAH Survey (March 2008)
Organization: Flex Monitoring Team
This report describes current CAH quality improvement initiatives and participation in quality reporting and benchmarking initiatives.

Critical Access Hospital Year 2 Hospital Compare Participation and Quality Measure Results (April 2007)
This report examines the second year participation and quality measure results for CAHs in the CMS Hospital Compare public reporting database for hospital quality measures.

Critical Access Hospitals (CAHs): Distance from Other Providers and Relocation of CAHs with a Necessary Provider Designation
This revised guidance explains the criteria by the CMS Regional Offices in determining whether or not a CAH applicant satisfies the regulatory requirement to be located more than 35 miles from another CAH or hospital and how to determine whether the CAH is eligible for application of the shorter, 15-mile standard due to mountainous terrain or lack of primary roads.

Differences in Measurement of Operating Margin: Flex Monitoring Team Briefing Paper
This briefing paper considers how differences in measurement of operating margin can affect the reported values.

Financial Impact of CAH Conversion on Rural Hospitals in Nebraska: A Report to the Nebraska CAH Steering Committee
This report from the Nebraska Center for Rural Health Research discusses how converting to CAH status has improved financial viability of rural hospitals in Nebraska.

Fitch Report on CAH Hospitals
An overview of strengths, risks, benefits, and requirements of critical access hosptials. This report also includes information on profiles of Fitch-Rated CAHs.

Flex Monitoring Team Data Summary Report No. 3: CAH Financial Indicators Report: Summary of Indicator Medians by State, August 2007
This Briefing Paper presents state and national median values of the twenty financial indicators included in the CAH Financial Indicators Report, a report that is distributed to each CAH administrator annually.

Hospitals That Have Not Yet Converted: Is CAH Still an Option? Questions and Issues for Small Rural Hospitals
This monograph presents a series of questions that State Flex Program managers and others should ask to better understand the reasons that hospitals have not converted to CAH status and assess the need for additional CAH conversion activities. These questions and several other issues that may present obstacles to CAH conversion are fully discussed in the report.

Improving Access to Primary Care
This policy, developed by the New Hampshire Department of Health, Bureau of Rural Health and Primary Care, addresses improvement of access to primary care and for the low-income uninsured, a requirement for CAH designation in New Hampshire.

"Let's Talk CAH"
This document, prepared by Pat Schou at the Illinois Department of Health, Center for Rural Health, is a three-page summary of the CAH program with some helpful Q & A.

Medicaid Treatment of CAHs by State
This excel spreadsheet contains information about Medicaid treatment for critical access hospitals on a state by state basis.

Midlevel Practioners in the ED
This study from the Minnesota Office of Rural Health and Primary Care looks into various aspects of using Midlevel Practioners in the Emergency Department's of Critical Access Hospitals verses Non- Critical Access Hospitals.

Summary Of Changes In CAH Interpretive Guidance: Distance from Other Providers and Relocation of Critical Access Hospitals with a Necessary Provider Designation
The September 7, 2007 revised critical access hospital (CAH) location and relocation interpretive guidelines supersede the November 14, 2005 issued in S&C-06-04.

Trends Over Time in the Provision of Skilled Nursing Care in Critical Access Hospitals
Focusing on critical access hospitals and cost-based reimbursement, this study observes trends in the delivery of skilled nursing facility services in swing beds and hospital-based units during a period of drastic changes in Medicare payments for post-acute care.

Organizations

American Hospital Association
This site contains legislative and regulatory updates pertaining to Critical Access Hospitals, a CAH FAQ page, and many other resources helpful for the critical acces hospital program.

Flex Monitoring Team
This site contains "Findings from the Field," which documents experiences from State and CAH perspectives on various initiatives within the Flex Program.