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Core Competencies for State Flex Program Excellence

This 2022 Guide offers anyone who manages and/or works on the Medicare Rural Hospital Flexibility (Flex) Program the opportunity to complete a competency self-assessment, identify areas of proficiency, recognize opportunities for improvement and development, and to use the Guide to understand and gather insight into what determines proficiency and how it can be developed. Tips, tools, and resources are also included in the Guide to provide additional background and support.

It is suggested that state Flex Program staff start using this Guide by first reading to understand what each competency is and what proficiencies are related to each competency. After reading the Guide, it is suggested that a state Flex Program complete the Core Competencies Self-Assessment. 

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National Rural Health Resource Center

The Guide lays out the 10 core competencies of an effective and impactful Flex Program, including: 

  • Developing Leadership and Workforce 

  • Managing the Flex Program 

  • Planning Strategically 

  • Managing Information and Evaluation 

  • Building and Sustaining Partnerships 

  • Understanding Policies and Regulations 

  • Strengthening Quality Reporting and Improvement 

  • Improving Financial Sustainability 

  • Understanding the Current and Future Health Care Environment 

  • Addressing Community Needs


FORHP strongly suggests that state Flex Programs complete this assessment at least annually. Results of the assessment will not be used by FORHP to determine future funding levels. Users are encouraged to complete the assessment multiple times to monitor progress on their continuous journey towards Flex Program excellence. Assessment results can be used to establish a baseline, create benchmarks, and aid in strategic planning and evaluation. This assessment should be taken from the perspective of the state Flex Program as a whole, and not as an individual person and their own proficiencies and competencies.

Core Competency Self-Assessment

In This Toolkit

The Flex Program and CAHs rely on leadership and a skilled workforce to advance program goals and deliver high-quality, high-value care for patients.
Managing the cooperative agreement is one of the primary responsibilities of state Flex Programs and includes: budgeting, cooperative agreement application writing, working with partners, information management, and reporting.
Planning ought to be purposeful, active, and relevant, with input from key stakeholders such as internal staff, rural provider leaders and staff, and the state rural health and clinic organizations.
Evaluation reporting to program stakeholders should be included in Flex Program activities. Reporting supports overall program transparency and development, stakeholder buy-in, engagement, and accountability.
State Flex Programs remain vital because of the web of relationships developed and maintained within communities, providers, networks, states, regions, and nationally. It is imperative that state Flex Programs have the skills, capacity, and commitment to build and sustain partnerships, new and old, to support rural providers and rural stakeholders.
State Flex Programs need to have an in-depth understanding of the policies and regulations governing the Flex Program, as well as a basic understanding of the policy-making process and other policies and regulations affecting rural providers.
State Flex Programs must understand QI principles, resources, and trends to support CAHs in advancing QI.
The Flex Program and CAH designation was established and remains in place because of the financial vulnerability of small rural hospitals. CAH financial and operational improvement is one of the required program areas of the Flex Program.
State Flex Programs can help CAHs transition into value-based systems, population health models, and future opportunities through education, network support, facilitation of new partnerships, and technical assistance.
It is important for state Flex Programs to understand the community needs of CAH and RHC service areas to develop or leverage program activities in support of health system development, community engagement, and population health improvement.

For additional Flex Program support, discussions, or technical assistance, please contact TASC by phone at 877-321-9393 or email at

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,560,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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