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

Tools

CAH Financial Performance Indicators
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).

CAH Physician Survey
Michigan Center of Rural Health
An example of a survey of physicians at CAHs.

Critical Access Hospital Prototype
Health Resources and Services Administration
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
Washington State Department of Health, Office of Rural Health
This flowchart is a visual description of the decision making process for CAH designation.

CAH Program Technical Assistance Grants Fact Sheet
Colorado Rural Health Center
Includes 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
Nevada Center for Education and Health
The checklist 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
Linda Powell of Mountain States Group
Module includes 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. Click on the file you want to download.

Current Status of CAH Components
Michigan Center for Rural Health
Example of a grid that could be used to track data and services of CAHs.

"Necessary Provider" Definitions
Technical Assistance and Services Center (TASC)
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
Linda Powell of Mountain States Group
Information on survey methods and how to conduct a patient satisfaction survey. Patient satisfaction survey and report templates are also included.

Sample Letter of Support for CAH Conversion
Illinois Critical Access Hospital Network
Sample letter that would come from a State office to a hospital indicating their support of the hospital converting to a CAH that could be used in the CAH conversion application. This sample comes from Pat Schou with the Illinois Critical Access Hospital Network.

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

Starting a Rural Health Clinic - A How-To Manual
Health Resources and Services Administration
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
Linda Powell of Mountain States Group
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.

Swing Bed Policy and Procedures
Illinois Department of Health, Center for Rural Health
Policies and procedures that are suggested for the Swing Bed facility in a CAH.

Survey Tools

Transforming Hospitals: Designing for Safety and Quality
Agency for Healthcare Research and Quality
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.

Resources

CAH Fact Sheet
Centers for Medicare and Medicaid Services
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
Flex Monitoring Team
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.

Critical Access Hospital Legislative History
American Hospital Association
An overview of all of the CAH legislation that has been passed since 1997.

CAH Status Report
The Center for Rural Health, School of Medicine, University of North Dakota
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
Illinois Department of Public Health, Center for Rural Health
Lists benefits, requirements, and expectations of CAHs.

CMS Critical Access Hospital (CAH) Claims
Centers for Medicare and Medicaid Services
Providers submitting claims to Medicare fiscal intermediaries for CAH anesthesia and ambulance services are affected by this change.

The Capital Investment Needs of CAHs: Fire and Life Safety Code Compliance and Organizational Performance
Flex Monitoring Team
Survey questions focus on access to capital ascertained information on critical fire and life safety code deficiencies in need of correction, total capital needs for correcting all existing fire and life safety deficiencies, immediate capital needs considered essential for efficient and effective operation and experiences acquiring capital to meet identified needs.

The Community Benefit and Impact of Critical Access Hospitals: The Results of the 2007 CAH Survey (March 2008)
Flex Monitoring Team
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
NORC Walsh Center for Rural Health Analysis and RUPRI Center for Rural Health Policy Analysis
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
Rural Assistance Center
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)
Flex Monitoring Team
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)
Flex Monitoring Team
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 Hospital Year 3 Hospital Compare Participation and Quality Measure Results (September 2008)
Flex Monitoring Team
Examines the third 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
Centers for Medicare and Medicaid Services
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
Describes how differences in measurement of operating margin can affect the reported values.

Federally Qualified Health Center Fact Sheet
Centers for Medicare and Medicaid Services
Provides information about Federally Qualified Health Center (FQHC) designation; covered FQHC services; FQHC preventive primary services that are not covered; FQHC payments; and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Financial Impact of CAH Conversion on Rural Hospitals in Nebraska: A Report to the Nebraska CAH Steering Committee
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
Fitch, Inc.
An overview of strengths, risks, benefits, and requirements of critical access hospitals. This report also includes information on profiles of Fitch-Rated CAHs.

CAH Financial Indicators Report: Summary of Indicator Medians by State, August 2007
Flex Monitoring Team
Describes 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
Technical Services and Assistance Center (TASC)
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.

Impact of CAH Conversion on Hospital Finances and Mix of Inpatient Services (Final Report)
Rural Health Research and Policy Centers
Examines Medicare Cost Report and claims data for hospitals before and after CAH conversion in order to better understand changes in hospital costs associated with CAH conversion, factors associated with any cost growth, and changes in the mix of services provided by the facility.

Improving Access to Primary Care
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"
Pat Schou, Illinois Department of Health, Center for Rural Health
Summary of the CAH program with some helpful Q & A.

Medicaid Treatment of CAHs by State
Technical Assistance and Services Center (TASC)
Information about Medicaid treatment for critical access hospitals on a state by state basis.

Midlevel Practitioners in the ED
Minnesota Office of Rural Health and Primary Care
Describes various aspects of using Midlevel Practitioners in the Emergency Departments of Critical Access Hospitals verses Non-Critical Access Hospitals.

The Capital Investment Needs of Critical Access Hospitals (CAHs): Results of the 2007 National CAH Survey
Flex Monitoring Team
"Survey findings suggest that access to capital has improved since 2004. Although the increase in successful loans for facility replacement may reflect the larger trend occurring in the hospital sector, CAH replacements are occurring for hospitals that previously could not meet investment-grade benchmarks."

Policy Brief: The Capital Investment Needs of Critical Access Hospitals (CAHs): Results of the 2007 National CAH Survey
From the Flex Monitoring Team: "Survey findings suggest that access to capital has improved since 2004. Although the increase in successful loans for facility replacement may reflect the larger trend occurring in the hospital sector, CAH replacements are occurring for hospitals that previously could not meet investment-grade benchmarks."

Rural Health Clinic Fact Sheet from 2008
Centers for Medicare and Medicaid Services
Provides information about Rural Health Clinic (RHC) designation; covered RHC services; RHC payments; and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Sole Community Hospital Fact Sheet
Centers for Medicare and Medicaid Services
Provides information about Sole Community Hospital classification and payments.

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

Swing Bed Fact Sheet
Center for Medicare and Medicaid Services
Provides information about the requirements hospitals and Critical Access Hospitals must meet in order to enter into a swing bed agreement under which they can use beds, as needed, to provide either acute or Skilled Nursing Facility care.

Trends Over Time in the Provision of Skilled Nursing Care in Critical Access Hospitals
North Carolina Rural Health Research & Policy Analysis Center
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.