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Georgia Office of Rural Health

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CAH Quality Improvement

The Georgia Flex Program works in collaboration with the Georgia Hospital Association (GHA) to implement the Medicare Beneficiary Quality Improvement Program (MBQIP) activities. GHA provides web-based software, quarterly webinar training, and face-to-face meetings.  They also provide extensive technical support for all 30 critical access hospitals (CAHs) for abstraction and public reporting of the four required quality domains outlined in MBQIP including Patient Safety/Inpatient measures, Core Patient Engagement Measures, Core Care Transitions, and Core Outpatient measures. 

GHA also develops and distributes comparative measure dashboards quarterly for all 30 CAHs for continuous monitoring and improvement. The hospital-specific dashboards are utilized to identify areas in need of improvement and to develop action plans. GHA also provides a collaborative learning framework focused on the implementation of the Core Elements of the Center for Disease Control's (CDC) Antibiotic Stewardship Program.

Additionally, a cohort of 15 CAHs are targeted to participate in the Culture of Patient Safety Survey (CoPS).  

CAH Operational and Financial Improvement

The Georgia Flex Program utilizes Georgia Southern University Research and Service Foundation (GSU) to implement operational and financial improvement activities. In annual cohorts of 15, GSU will conduct financial and operational hospital service-line assessments and SWOT (Strengths, Weaknessess, Opportunities and Threats) Analyses throughout the year. These analyses will be utilized to develop hospital-specific action plans for improvement. GSU will also facilitate three-year organizational strategic planning sessions with the development of implementation plans for a cohort of at least nine annually.

Stakeholder and community engagement assessments with interventional action plans will be conducted along with the provision of training on rapid cycle approaches for data-driven operational improvement. Leadership strategies will be implemented through workshops and seminars. Overall program evaluations will be conducted annually to identify programmatic activities in need of modification or a redirected focus. 

CAH Population Health Improvement

Rural communities in particular struggle to provide access to much needed behavioral health services, and according to CAHs, patients have very often spent hours, sometimes days, in the emergency department (ED) waiting to be transferred to a treatment facility. Behavioral health care needs are not met in rural Georgia communities because adequate services are not available.

In light of Georgia's dire need for behavioral health services, the Georgia State Office of Rural Health (SORH) partnered with HomeTown Health to develop the Vision and Education for Rural Behavioral Health (VERB) Program. The goal of this program is to build capacity of CAHs to achieve measurable improvements in the health outcomes of their communities. Specifically, it will assist hospitals in engaging community stakeholders to address their population's behavioral health needs.

The VERB program will assist hospitals in their population health efforts surrounding the behavioral and mental health needs of individuals in their community empowering hospitals to take ACTION in the areas of: Abandoning Stigmas; Care and Case Management; Train Providers; Identify and Screen; Organize Resources, and Navigate Payments. Hometown Health (HTH) will assist CAHs in engaging with community stakeholders and public health experts to identify two behavioral health subcategories (i.e. addiction, suicide, depression, etc.). Education, support, and provider and staff training will be provided relative to the CAH's specific community behavioral health needs. Ongoing best practice sharing, peer networking, and  community input will help guide the focus of additional program needs or realignment. The project goal is to provide a needed behavioral health service line or partnership that will serve to improve the health of the community. 

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

The Georgia State Office of Rural Health (SORH) has partnered with Georgia Southern University Research and Service Foundation (GSU) to provide a CAH Leadership Community of Practice (CoP).

The CoP Network is a platform where CAH leadership collaborate to find resolutions to common challenges by networking, sharing best practices, experiences, and successful program models. GSU will serve as a moderator to facilitate the learning community and provide a forum for sharing and collaboration. The CoP Network will also serve to provide feedback to the Flex Coordinator and identify program needs relative to CAHs. The CoP Network was provided in response to CAH leadership requests for a means to network with peers and is funded with state dollars. 

Program Statistics

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Type of Organization State Government
Staffing (FTE) 1.5
Website None Provided
Number of CAHs 30

Flex Program Staff

Dawn Waldrip
Flex Coordinator, Georgia and Director, Hospital Services
(229) 401-3088

Flex Coordinator since January 2019

Amanda Laughter-Sutton
Program Operations Specialist, Georgia
(229) 401-3092

Program Specialist since March 2020

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, $1,009,121 (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.