State Flex Program Staff Sustainability Guide and Toolkit

August 2022
National Rural Health Resource Center (The Center)

Turnover of key state Flex Program staff has been a problem since the inception of the Medicare Rural Hospital Flexibility (Flex) Program. Given the increasing complexity of health care and the many dimensions of the Flex Program, there is a steep and time-consuming learning curve for new Flex Program staff. This guide is designed to help state Flex Programs recruit good Flex Program staff, train them successfully, retain them longer, and then plan an orderly process of finding and training new staff before the outgoing staff leave.

The Staff Sustainability Cycle is a process for improving the retention of high-performing Flex Program staff. The guide outlines specific strategies and has practical tools for addressing each component of the cycle, which consists of: 

  • Recruiting
  • Onboarding
  • Learning & Development
  • Engagement & Retention
  • Succession Planning

By following the relevant and practical recommendations in this guide, state Flex Programs can strengthen staff engagement and retention through the Staff Sustainability Cycle described within – thus ensuring continuity of the critical programs they provide to support rural health.

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.