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Georgia State Office of Rural Health

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Program Area: Support for Quality Improvement

Medicare Beneficiary Quality Improvement Project (MBQIP) activities are focused on the four different quality domains. Building and maintaining the participation of all critical access hospitals (CAHs) in MBQIP through these sets of quality measurement and reporting activities are required.

The Georgia Flex Program works in collaboration with the Georgia Hospital Association (GHA) to implement MBQIP activities. The GHA provides access to performance measurement system software that helps hospitals collect, report, and analyze clinical quality data. Real-time reporting provides immediate feedback on performance for hospital quality improvement opportunities. CAHs have access to ongoing technical assistance for data collection and reporting to the Hospital Compare website.

For a second year, the Georgia Flex Program will utilize the Institute for Healthcare Improvement (IHI) “Breakthrough Collaborative” model for technical support for CAH implementation of core components of the Rural Hospital Antibiotic Stewardship program. 

Program Area: Support for Financial and Operational Improvement

The Georgia Flex Program utilizes Georgia Southern University Center for Public Health Practice and Research and College of Business Administration to implement the Financial and Operational Program Area. In this fourth year of funding, the contractor will focus on Strategic Planning and continued Lean Six Sigma Green Belt Certification support for measuring current practice and the impact of technical assistance.

In addition, the Georgia Flex Program partners with HomeTown Health to assist the rural hospitals with expert training and technical assistance for their staff to understand and adhere to the requirements of Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP) and corresponding Interpretive Guidelines, to assist with billing and utilization review activities, measuring outcomes and value to drive program marketing, and a data-driven approach to service line development and opportunity.

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

The Georgia Flex Program will partner with the Georgia Department of Public Health Chronic Disease division to provide CAHs guidance, training and support to develop and implement a Diabetes Prevention Program (DPP) to decrease the number of people at high risk for developing type 2 diabetes in rural communities. The program will provide:

  • Education on the importance of DPP and how to become a Centers for Disease Control and Prevention (CDC) recognized lifestyle change program
  • Identify appropriate individuals to become trained lifestyle coaches. Individuals must be trained as a lifestyle coach prior to the implementation of the National Diabetes Prevention Program. 
  • Education on patient recruitment and how to utilize the Electronic Health Record (EHR) to identify eligible individuals
  • Assistance in applying to become a Medicare Diabetes Prevention Program (MDPP) supplier

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

For a majority of Georgia CAHs, the Swing Bed Program is a significant portion of their hospital’s day to day operations. Nationally, CAHs are exempt from regulations requiring the collection of swing bed quality measure data. As a result, CAHs are not uniformly able to demonstrate the quality of care provided to their swing-bed patients or compare it to national benchmarks. In addition, the lack of quality data for their swing bed services limits the ability of CAHs to participate in alternative payment models involving post-acute care.

To measure the performance and outcomes related to CAH Swing Bed Programs, Georgia CAHs are participating in a national field testing and performance improvement project supported by Stroudwater Associates in collaboration with the University of Minnesota Rural Health Care Research Center.

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

Partnering with the Georgia Hospital Association with the use of their Georgia Discharge Data System data analytic tools to enhance capability of hospital benchmarking. 

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


Program Statistics

Type of Organization State Government
Staffing 2.0 FTEs
Number of CAHs 30
Website URL Organization Website

Flex Program Staff

Patsy Whaley
State Office Director, Georgia
(229) 401-3081

Specialty Areas / Background

Patsy has more than 35 years of health care experience including administration of critical access hospital (CAH) and prospective payment system (PPS) hospitals, health information management and quality improvement.

State Office Director since August 2015

Dawn Waldrip
Flex Coordinator, Georgia
(229) 401-3090

Flex Coordinator since January 2019

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.