Arizona State Flex Profile

Top Flex Activities

Program Area: Support for Quality Improvement: 

The Arizona Rural Hospital Flexibility Program (AzFlex) provides training and education to Arizona’s critical access hospitals (CAHs) on the Medicare Beneficiary Quality Improvement Project (MBQIP) by monitoring and evaluating data, creating and disseminating reports to CAH leadership and reviewing best practices so that Arizona CAHs can reach and sustain 100 percent MBQIP reporting. 

Activities include:

  • Monthly webinars with CAH Quality Network
  • Onsite technical assistance site visits conducted to educate and assist CAHs in MBQIP
  • Monthly MBQIP reminders and tips
  • Customized reports with hospital scorecards on the MBQIP domains
Please share a success story about reporting quality data or using quality data to help Critical Access Hospitals (CAHs) in your state improve patient care: 

Emergency department transfer communication (EDTC) data is so current that when reports are run, data sharing is done immediately. One Arizona CAH Quality Director goes directly to the Emergency Department when the data is pulled to make sure they are doing all the best practices for the patients. Success is identified when the data is used to drive change and, in this case, it is used immediately.

Program Area: Support for Financial and Operational Improvement: 

AzFlex runs a leadership network that meets monthly. This is a great way for the CAHs to network and share resources. Co-chairs from two Arizona CAHs help plan and guide the discussion. AzFlex retains a subcontractor to conduct financial and operational assessments at two Arizona CAHs for fiscal year (FY) 2016 based on their low to negative margins. The consultation involved an in-depth review of the hospitals’ operations and finances. The subcontractor will submit a findings report and discuss results of benchmark analyses, best practices and provide recommendations. The expected long-term result is to improve financial and operational metrics for these CAHs. Chief Financial Officers (CFOs) will share the process, results, lessons learned and best practices to all Arizona CAH leadership. Measurement of this activity may take up to two years to show impact. Results are being tracked through the annual Flex Monitoring Team (FMT) Financial Indicator Reports (CAHFIR). 

There has been a dramatic reduction in uncompensated care for Arizona hospitals over the last two years. This correlates with Affordable Care Act (ACA) coverage provisions that began in January of 2014, expanding Medicaid and implementing the federally facilitated Arizona Marketplace, and increasing funding by the state through the CAH pool. 

Billing and coding workshops continue to be sponsored by AzFlex. At CAHs, the coders focus on many more areas than a larger tertiary hospital, therefore the CAH coders need more resources. Measurement is based on the claim denial rate percentage prior to the course. A listserv was created for the CAHs to reach out to the other CAHs for billing and coding issues.

Program Area: Support for Population Health Management and Emergency Medical Services Integration: 

AzFlex identified a new activity for FY 2016, focusing on an analysis of CAH community health needs assessments (CHNAs) to identify common issues and priorities to address. Several Arizona CAHs are in the process of updating their three-year plans while other CAHs’ CHNAs are still current. AzFlex will use the review to help CAHs measure the impact of their respective community-wide efforts.

AzFlex developed the 2016 Arizona Statewide Emergency Medical Services (EMS) Needs Assessment survey and continues to distribute it to EMS, fire and ambulance agencies statewide. Results of the survey, scheduled for Spring 2017, will help support EMS direction and scope of efforts within the 14 Arizona CAH communities as well as other Arizona rural and urban communities. AzFlex was asked for a copy of the Arizona survey by several states who were considering a similar initiative.

Please provide information about Collaboration/Shared Services (specifically connected to population health management): 

AzFlex continues to collaborate with Arizona Department of Health Services (ADHS) Bureau of EMS and Trauma System, and the 40 trauma centers (Level I, III and IV) in the state. The Arizona Trauma Managers Workgroup, established 2010, continues to meet quarterly with rotating in-person meetings at trauma center sites around the state. In addition, over 100 people actively participate in a trauma program manager listserv (managed and maintained by AzFlex) to share ideas, policies and best practices. One significant outcome of this workgroup has been the design and distribution of a Trauma Injury Prevention Survey, used to better understand the current status of injury prevention programs in Arizona's 40 trauma centers. Efforts began in January 2016 with the formation of a Survey Development Committee. The survey was distributed during the summer and fall and analysis is expected to be complete by Spring 2017. Based on survey results, ADHS, Arizona's trauma centers and other partners will determine suitable objectives and initiatives for a possible statewide injury prevention project.

Program Area: Support for Designation of CAHs: 

AzFlex continues to assess the interest of eligible hospitals for CAH designation. Two hospitals are currently eligible for CAH designation in Arizona. AzFlex is providing technical assistance to one eligible hospital interested in exploring CAH designation. Another Indian Health Services (IHS) hospital is in the process of being built and will be eligible for CAH designation based on size and location to other hospitals.

Please provide information about any efforts to assist CAHs/communities and partner organizations in the transition to value-based care: 

Through the AzCAH Leadership Network, resources are shared on the transition to value-based care through conference calls, webinars and bringing in experts to speak on the subject at the annual Rural Health Conference/Performance Improvement Summit.

Please provide information about network activities in your state to support Flex Program activities (such as financial improvement networks, CAH quality networks, operational improvement with CEOs or EHR workgroups): 

AzFlex runs a variety of networks. The networks include a Leadership Network, Quality Network, Trauma Program Managers Workgroup, Strategic Quality Support System (SQSS), Billing and Coding as well as electronic health record (EHR) workgroup specific to a EHR vendor. Most of the networks meet face to face and or by webinar and some networks were set up as a listserve to communicate messages or issues in a fast productive way. All of the above networks have proven to be extremely valuable for the CAHs to network and share information. 

Please provide information about cross-state collaborations you may be working on related to the Flex Program: 

Since 2013, AzFlex has worked with the Bureau of EMS and Trauma System on implementing a state-wide trauma performance improvement initiative focused on:

  • Reducing Level III/IV Emergency Department dwell times to Level I Trauma Centers
  • Reducing transfers after admissions
  • Reducing deaths outside of trauma centers
  • Increasing trauma billing efficiency

IArizona’s Trauma Level I Centers have taken turns to host in-person meetings for trauma program managers around the state. These meetings address the Arizona trauma plan priorities of continuing the performance improvement efforts, strengthening injury prevention, supporting utilization of the trauma registry and providing necessary resources on trauma billing.   

From the last Flex Program year, please describe a best practice you would like to share with other states: 

AzFlex has identified the following best practices in assisting with program implementation: 

  • Listservs  The Leadership, Quality, Trauma Program Managers and the Health Information Technology Listservs have been instrumental in sharing policies, procedures, requesting assistance and sharing information
  • Site Visits  One-on-one meetings with AzCAH leadership has been effective in engaging participation in program activities
  • MBQIP Resource Binder  Allowed AzFlex staff to educate CAHs on MBQIP in a standardized format and allowed CAH personnel to understand the information and requirements in a user-friendly format 
  • Hospital-to-Hospital Technical Exchange  AzFlex encouraged and supported CAHs to visit each other for assistance and share best practices or approaches
  • University Graduate and Doctoral Students and Faculty  AzFlex taps into health sciences expertise using University of Arizona students and faculty to support programmatic efforts
  • Linking to Existing Events  AzFlex jointly hosts the CAH Performance Improvement Summit with the Annual Arizona Rural Health Conference to both enhance relationships and networking with experts and colleagues, and explore current state and national issues, challenges and opportunities in Arizona’s rural communities

Program Statistics

What type of organization is your Flex office housed in?: 
What is the number of full time employees (FTE) in your Flex office?: 
How many CAHs are in your state?: 
Do you have any hospitals interested in converting to CAH status?: 

Additional Information

Flex Program Staff

Daniel Derksen, MD
Director, Center for Rural Health, Arizona
(520) 626-3085

Specialty Areas / Background

Director of the Center for Rural Health (CRH), Walter H. Pearce Endowed Chair and Professor, Director of the Community, Environment and Policy Division at the University of Arizona’s Mel and Enid Zuckerman College of Public Health. As CRH Director, he oversees the State Office of Rural Health, the Rural Hospital Flexibility Program (Flex), and the Small Rural Hospital Improvement Program (SHIP). He chaired the American Academy of Family Physicians Commission on Governmental Advocacy in 2013-14. He served on the American Hospital Association’s Governing Council Section on Rural or Small Hospitals, and on the Arizona Hospital and Healthcare Association Small Rural Hospital Constituency Group.

State Office Director since July 2013

Jill Bullock
Flex Coordinator, Arizona
(520) 626-3722

Specialty Areas / Background

  • Network development
  • Physician outreach
  • Healthcare program navigation and Medicaid eligibility 

 Coordinator of Rural Health Services since September 2011

Joyce Hospodar
Manager, Health Systems Development, Arizona
(520) 626-2432

Specialty Areas / Background

  • Health services research including quality improvement and health systems development
  • Health planning
  • Network development

Health Systems Development Manager since 2001

Bryna Koch
Special Projects Coordinator/Internal Evaluation, Arizona
(520) 626-6253

Specialty Areas / Background

  • Evaluation
  • Evaluation capacity building at the local, state and national levels

Special Projects Coordinator/Internal Evaluation since August 2016

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, $1,100,000 (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.