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State of Maine, DHHS, Maine CDC, Office of Rural Health and Primary Care

Top Flex Activities

CAH Quality Improvement

The Maine Flex Program conducts quality improvement (QI) training, resource management, project management, technical assistance, and support for the inpatient and outpatient areas for critical access hospitals (CAHs) in the state of Maine. The office works with content experts, respected healthcare leaders, and other supporting healthcare partner organizations to facilitate the Maine CAH Quality Improvement (QI) Network.  This network meets quarterly face-to-face, yet they also collaborate in-between quarterly meetings to strategize and support each other on their respective work to improve the hospitals' effort to provide high-quality care for the rural communities they serve.

CAH Operational and Financial Improvement

The Maine Flex Program leverages federal and state content experts and other respected healthcare finance leaders and organizations across Maine and the United States. The Maine Flex Program has designed an operational and financial needs assessment that is complimentary to the Small Hospital Improvement Program (SHIP) grant goals and objectives. This enables the most efficient use of CAH Revenue Cycle Management staff time from both front and back-of-business finance operations. They identify opportunities for improvements in current revenue and financial management practices, as well as provide proactive planning for the prevention of potential losses in revenue by planning for Diagnosis Related Groups (DRG), ICD-10, as well as other coding and regulation changes that impact CAH financial health. The Maine Flex Program also facilitates the decision support branch of this work through the Maine CAH Chief Financial Officer (CFO) Network.

CAH Population Health Improvement

Meeting the unique health needs of the rural communities across the state of Maine has always been a priority for the CAHs. The community health needs assessment (CHNA) process and the county needs assessments were updated in July 2019. County-identified health priority areas include addressing mental health, substance use, social determinants of health, access to care, and older adult health and healthy aging. Additional identified health needs ranged across healthcare quality, chronic disease self-management support, and cancer. The Maine Flex Program will be utilizing the county CHNA report finding to crosswalk with the various programs and Quality Improvement (QI) projects being undertake by the CAHs to identify logical overlapping opportunities for interventions, QI projects, and leveraging of existing reporting systems to support monitoring and evaluation of the CAH efforts to address community health needs identified in the various service area across Maine.

Rural Emergency Medical Services (EMS) Improvement

The Maine Flex Program has a long-standing partnership with the Maine Emergency Medical Services (EMS) by way of this Flex Program. This will lead to the continuation of the Maine EMS Trauma System project. Recommendation and guidance are provided to CAHs and other rural emergency care providers with a statewide trauma system plan, a technical assistance program, and clinical consensus guidelines for patient care and transfers. Also, continuing within this program area will be the Maine Stroke Alliance with the established mission “To create an integrated, multidisciplinary, regional system of stroke care that addresses the prevention, acute and subacute treatment, recovery and secondary prevention of cerebrovascular disease with an ultimate goal of ensuring that all patients in the State of Maine have access to comprehensive, high-quality, and cost effective care at all levels of stroke acuity regardless of location."

Innovative Model Development

The Maine Flex Program works with the CAHs in their network to assist with the transition to value-based care and purchasing. CAHs are provided with individualized portfolios in regard to the Hospitals Strength Index Performance Report as well as in-depth financial and operational needs assessments that enable them to start planning their prospective planning for the shift from volume to value-based care and payment contracting.

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

The Maine Flex Program brings together various networks including the Chief Executive Officer (CEO) Network, the Chief Nursing Officer (CNO) Network, the Chief Financial Officer (CFO) Network, Quality Director Network, and the Nurse Manager Network. All are comprised of CAH staff in specific functional roles, which determines the network in which they participate. Additionally, the Rural Health and Primary Care Program staff and a Maine Hospital Association staff member participate in the CEO and CFO networks. These networks serve as unique arenas for Maine CAHs to come together as a group and discuss their challenges in the CAH realm as well as share best practices, network, and identify potential projects. The high level of sharing that happens in these networks (and the lack of competition between CAHs) gives purpose to the Flex Program.

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

The Maine Flex Program collaborates with its peers in New Hampshire, Vermont, and Massachusetts to provide educational resources for CAH staff. Known as the New England Performance Improvement (NEPI) Network, the states work together in collaboration with the New England Rural Health Roundtable to maximize services by pooling a set amount of Flex funds from each state. NEPI provides access to:

  • Institute for Healthcare Improvement (IHI) Open School and Virtual Expeditions
  • Reimbursement for professional certifications in quality, patient safety, antibiotic stewardship, and others
  • Financial support for the Trauma Nurse Core Course or other relevant training
  • NEPI is open to changing the support provided based on the most pressing needs identified by the CAHs

Program Statistics

Do you have any hospitals interested in converting to CAH status?:
Type of Organization State Government
Staffing (FTE) 1.5
Website Organization Website
Number of CAHs 16

Flex Program Staff

Nicole Breton
State Office Director, Maine
(207) 287-5503

Specialty Areas / Background

Nicole has worked in the health field for over twenty years with a specialty of dentistry. She also worked at the Maine Center for Disease Control in the Oral Health Program, managing the School Based Prevention Programs and other oral health initiatives. Nicole enjoys the work being done in the State of Maine Rural Health and Primary Care Program.

State Office Director since August 2017

Nathan Morse
Flex Coordinator, Maine
(207) 287-5427

Flex Coordinator since July 2018

Merica Tripp
Planning & Research Associate II, Maine

Planning & Research Associate since November 2017

Erica Dyer
Office Associate II, Maine

Began in November 2020.

Joan Mank
Office Associate II, Maine
(207) 287-5562

Specialty Areas / Background

Reception, contracts, and reports

Office Associate since October 2002

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.