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Colorado Rural Health Center

Top Flex Activities

Program Area: Support for Quality Improvement

The Colorado Rural Health Center (CRHC) continues to build on previous work in the area of quality improvement with the Critical Access Hospital (CAH) Quality Network, Regional Quality Improvement (QI) Workshops and Improving Communications and Readmission (iCARE) program, among other efforts. To measure the benefit of these projects, CRHC utilizes Medicare Beneficiary Quality Improvement Project (MBQIP) data, benchmarking system reports, Critical Access Hospital Measurement and Performance Assessment System (CAHMPAS) reports, as well as additional data and information gathered from programs such as iCARE.

Please share a success story about reporting quality data or using quality data to help CAHs in your state improve patient care.

The following is a success story from one of Colorado’s CAHs located in Walsenburg, as reported by their Quality Improvement Manager:

The hospital is regularly successful across all MBQIP outpatient (OP) measures, typically scoring in the top 10 percent. Not content with that score, the hospital continues to dig into their data to uncover additional improvement opportunities. One example is the work done on Outpatient Measure 5 – Median time to electrocardiogram (EKG). Working with CRHC, the hospital formed a multidisciplinary team with members from pharmacy, nursing, emergency department (ED) and cardiopulmonary to address process improvement. The team created process flow maps to help identify barriers to getting EKGs done in a timely fashion. They soon realized that the lab also had a major role in the process, so the lab manager was included. Some of the in-house process changes included ensuring the EKG is completed first, and the use of overhead paging to alert staff that a patient with chest pain is on the way. The hospital’s median time to EKG has gone from 17 minutes to 6 minutes, (state median is 11 minutes) and they anticipate that the current quarter data will show even more improvement.

Program Area: Support for Financial and Operational Improvement

In the area of Financial and Operational Improvement, CRHC is offering activities and support that build upon previous achievements. Annually, CRHC updates its CAH Swing Bed and Utilization Management Resource manuals and hosts a webinar series on these topics to provide updates and training on any changes to regulations and best practices. CRHC is also continuing to expand its CAH Financial Workgroup with CAH Chief Executive Officers (CEOs), Chief Financial Officers (CFOs) and other members of the CAH finance team. Additionally, CRHC offers education to CAHs through its annual CAH Workshop. CRHC measures the impact of these activities through CAHMPAS and other rural hospital data.

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

CRHC does not address this program area through Flex directly. CRHC does provide this support and assistance to CAHs and other rural facilities statewide through its other programs. The results and related data the organization gathers through these other programs all inform various core areas within CRHC’s Flex work.

For example, CRHC is utilizing its Health Awareness for Rural Communities (HARC) databank of over 400 county-level demographic and population health measures to develop reports for each CAH in Colorado that show the top and bottom three population health metrics for their counties. These reports are developed in order to provide information to inform CAHs' responses to service needs for their communities. CRHC also analyzes population health metrics for rural Colorado to draw conclusions about needs and opportunities, and works to synthesize this data with iCARE and MBQIP data. 

In the area of emergency medical services (EMS) integration, CRHC has contracts with the Colorado Department of Public Health and Environment to support EMS systems throughout the state with access to funds for training and education.

Please provide information about Collaboration/Shared Services

CRHC connects with local public health and other community agencies to help raise awareness of community resources. CRHC also collaborates with the state health department to link providers to technical assistance in an effort to strengthen compliance and participation in state trauma system. CRHC is incorporating elements of population health management and EMS systems through its work in iCARE. Through iCARE, CRHC is working with facilities on their community engagement goals to meet population needs.

Program Area: Support for Designation of CAHs

One of the original intents of the Flex Program was for states to assist eligible rural hospitals to convert to CAH status to safeguard access to care in vulnerable rural areas. While these activities have decreased over the years as most eligible hospitals have already converted, there is still a periodic need for these assessments and assistance. CRHC has provided recent assistance in this area. Two facilities recently converted to CAH designation and two additional facilities are in the process of completing feasibility analyses with the intent to convert from prospective payment system (PPS) hospitals to CAHs. CRHC continues to keep resources pertaining to the CAH conversion process up-to-date and will offer assistance to any hospital inquiring about its options.

Program Area: Support for Integration of Innovative Health Care Models

CRHC expanded on the work occurring through its iCARE program to fulfill its vision to create a community-based, rural-relevant program. iCARE began with Colorado’s CAHs in 2010 through Flex. In 2012, CRHC received additional state funding which allowed the program to expand to include CAH provider-based clinics. Through this new innovation opportunity with Flex, CRHC moved forward with opportunities to raise awareness amongst other care providers in rural communities. CRHC offers an avenue to explore the care coordination and communication processes between hospitals, clinics, and other care providers including EMS, long-term care, home health and others through the existing monthly iCARE webinar series. Discussion topics within these areas include information transfer protocols between care settings, data transfer, patient communication and follow-up processes.

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

Avoidable readmission rates and transitions in care have come under close scrutiny by payers and policymakers because of the potential for high savings. Tackling this issue is an opportunity to improve quality and reduce costs in the health care system. Although readmission rates among Colorado CAHs, by virtue of their volume, may be small, there is opportunity for the state to stay ahead of national trends, spotlight the great services Colorado’s CAHs and rural clinics are providing, make improvements in processes that will help maintain low readmission rates and continue to showcase the hospitals and clinics' status as leaders in their communities.

The iCARE program has resulted in fewer unnecessary hospital readmissions and improvements in quality outcomes and cost efficiency. Additionally, Colorado is a state that is at the cutting edge of many national initiatives including the Agency for Healthcare Research and Quality (AHRQ) Evidence Now Southwest (ENSW) program, the Centers for Medicare & Medicaid Services (CMS) and State Innovation Model (SIM) initiative. CRHC is a subcontractor on ENSW and SIM to transform health care delivery by building critical infrastructure to help smaller primary care practices apply the latest medical research and tools to improve heart health (ENSW) and behavioral health (SIM) by providing continuous quality improvement with our experienced staff, and technical assistance support from health information technology (HIT) staff.

Please provide information about network activities in your state to support Flex Program activities.

The iCARE project brings hospitals and their provider based clinics together to help improve communication and readmissions. Currently, CRHC has 22 CAHs and 32 clinics participating in the project.

CRHC hosts monthly iCARE webinars where data is examined and best practices discussed. The webinars are a great forum for peer learning and provide the opportunity for facilities to hear from one another what they have been working on, what has been working well and where they may have encountered barriers.

CRHC holds Regional Quality Improvement Workshops each year. They are repeated in multiple locations in an effort to mitigate the distance each facility has to travel. Topics include quality improvement methodologies as well as education and training for MBQIP data submission and analysis.

CRHC manages the CAH Peer Review Network in an effort to provide objective rural providers chart reviewers from other CAHs who have an understanding of the unique working conditions of rural providers.

CRHC also manages a CAH Financial Workgroup with quarterly webinars where CAH CEOs and CFOs learn about and discuss the latest financial trends and any new regulations.

CRHC, in partnership with the state quality innovation network – quality improvement organization (QIN-QIO), hosts bi-monthly CAH Quality Network Webinars that focus on utilizing quality improvement methodologies to build capacity for MBQIP measure reporting and education.

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

Telligen is the QIN-QIO for Colorado, Illinois and Iowa for quality improvement, value-based purchasing program support and technical assistance. Telligen has been a supporter of the CAH program and has invited CRHC and CAHs to participate on their cross-state hospital quality reporting/improvement update webinars. These webinars allow participants to share best practices and discuss barriers from providers. 

CRHC is continuing as an operating partner with Healthy Transitions Colorado, a statewide initiative which is working to link best practices and resources about care transitions and readmissions efforts across the state.

Please describe how your state Flex Program has enhanced its use of data in the past year.

CRHC has implemented Electronic Health Record (EHR) User Group conference calls once each quarter with each of the EHRs and the facilities utilizing that vendor’s product. Items discussed include action plans/priority lists, EHR functionality, challenges related to data extraction and reporting, patient portals and disease registry modules. The biggest challenge continues to be the lack of functionality to pull data and generate reports out of the EHR in order to drive quality improvement and decision-making. The success is when a user willingly shares how they located and/or created a report to pull MBQIP and iCARE data and provides instructions on how the other facilities using that vendor’s product can do the same.

CRHC utilizes and distributes quarterly MBQIP, CAHMPAS and benchmarking data to assist CAHs with interpretation and improvement efforts. CRHC also utilizes the HARC Databank to compile and analyze population health metrics for rural Colorado to draw conclusions about needs and opportunities and working to synthesize this data with other data such as iCARE and MBQIP. This data is displayed in an infographic format and distributed semiannually.

Please share any resources or tools that you found useful in your state Flex Program's work this past year that you would recommend to your Flex Program colleagues.

CRHC found the Inpatient Outpatient (IP-OP) Comparison Quarterly Template useful in comparing CAH MBQIP measure performance.

Do you have any hospitals interested in converting to CAH status?:


Program Statistics

Type of Organization Non-profit Organization
Staffing 3.5 FTEs
Number of CAHs 31
Website URL Organization Website

Flex Program Staff

Michelle Mills
State Office Director, Colorado
(303) 832-7493

Specialty Areas / Background

Colorado Rural Health Center's (CRHC) CEO, Michelle has over 18 years of healthcare experience in quality improvement and patient safety. Michelle has worked extensively with hospitals, nursing homes, and physician offices, and she has been a catalyst for creating synergy for quality improvement and patient safety efforts. Michelle began working with CRHC in January 2010.

State Office of Rural Health Director since August 2012

Marcy Cameron
Flex Coordinator, Colorado
(303) 468-3498

Specialty Areas / Background

As the critical access hospital program manager, Marcy is responsible for helping meet the needs of hospitals in rural and underserved areas of Colorado. Marcy is a health care management professional who has over 14 years of experience with health care quality improvement organizations, federal government reporting programs and hospital services. Her experience includes providing technical assistance, education and quality improvement support.

Flex Coordinator since February 2016

Rachel Williams
Administrative Assistant, Colorado

Administrative Assistant since April 2017

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.