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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.