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Maine State Office of Rural Health and Primary Care

Top Flex Activities

CAH Quality Improvement

The Maine Flex Program  assists its state’s critical access hospitals (CAHs) through quality improvement (QI) training, resource management, project management, technical assistance, and support for the inpatient and outpatient aspects of the hospitals. This is done through the Maine CAH Quality Improvement Network which includes content experts, respected healthcare leaders, and other supporting healthcare partner organizations. Pre-COVID-19, this network would meet quarterly in a face to face setting with some collaboration between the facilities in between meetings. In the climate of COVID-19, the meetings are held via video conference. The network works together to strategize and support each other on their respective work to improve the hospitals’ efforts to provide high-quality care for the rural communities that they serve. Any topic or project specific trainings are scheduled as needed. All trainings are promoted to target a larger audience and CAH staff to maximize participation and completion to widen the effect the training has on multiple CAH hospitals. Through the assistance of one of their contractors, the Maine Flex Program can provide Telligen reports which are distributed to the individual CAHS and all data is reported unblinded at the quarterly meetings. They also work with the New England Rural Health Association (NERHA) to promote the Institute for Healthcare Improvement (IHI) Open School. The Open School provides an assortment of trainings that the CAH hospital staff can sign up for and complete.

CAH Operational and Financial Improvement

The Maine Flex Program utilizes federal and state content experts and other respected health care and finance leaders and organizations across Maine and the United States. They have designed an operational and financial needs assessment that compliments the Small Hospital Improvement Program (SHIP) grant goals and objectives. The needs assessment identifies opportunities for improvements in current revenue and financial management practices. It also provides an opportunity for 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 the financial health of the CAHs.

The decision support branch is also facilitated by the Maine Flex Program through the work of the Maine CAH Chief Financial Officer (CFO) Network. They use the SHIP grant CEO/CFO networks to identify projects and talking points for engaging communities and populations in identifying roles to act on financial planning, patient-centered care, enhancing community outreach and to develop CAH business sustainability plans for post-COVID 19. Various New England states have come together to operate as the New England Performance Improvement Network (NEPI). NEPI provides reimbursement for identified certifications and professionally recognized education programs for the staff of CAHS and other Rural Health Providers in a variety of topics which are subject to change based on the yearly needs assessment. The Maine Flex Program also offers trainings for rural health care providers and their support staff in Advanced Life Support in Obstetrics (ALSO).

CAH Population Health Improvement (optional, report if you have included in your work plan)

One of the priorities for the Maine CAHs is to meet the unique health needs of the rural communities across the state. Some of these priority areas include addressing mental health, substance use, social determinants of health (SDOH), access to care, and older adult health and healthy aging. Other health needs were identified as health care quality, chronic disease self-management support, and cancer. The Maine Flex Program will be using the community health needs assessment (CHNA) report to find a crossing point within the various programs and quality improvement (QI) projects that are currently being undertaken by the CAHs in order to identify logical overlapping opportunities for interventions, QI projects, and the use of existing reporting systems to support monitoring and evaluation of the CAH efforts to address community health needs across Maine.

Rural Emergency Medical Services (EMS) Improvement (optional, report if you have included in your work plan)

The Maine Flex Program has a long-standing partnership with the Maine Emergency Medical Services (MEMS). They have used this partnership with MEMS to ensure that all Maine CAHs receive direct technical assistance from the MEMS Trauma Advisory Committee (TAC). This comes from a direct request of the CAHs. 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. The Maine Flex Program plans to continue its partnership with MEMS to support and participate in the Maine Stroke Alliance. The Maine Stroke Alliance has the established mission statement “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.” The Maine Flex Program staff provides technical assistance and stroke care resources to CAH Networks and encourages the participation in the Maine Stroke Alliance Meetings.

Innovative Model Development (please complete this question if completed on cooperative agreement application)

The Maine Flex Program works with the CAHs in their network to assist with the transition of value-based care and purchasing. The CAHs are provided with individualized portfolios in regard to the hospital’s 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 cross-state collaborations you may be working on related to the Flex Program.

Maine, along with Massachusetts, New Hampshire, and Vermont, operates as the New England Performance Improvement (NEPI) Network to provide reimbursement for identified certifications and professionally recognized education programs for the staff of the CAHs and other rural health providers. Certifications and courses offered are on topics like patient safety, infection control, antibiotic stewardship, quality improvement science, risk management, trauma care, and psychiatric nursing. The topics can vary from year to year based on the annual need’s assessment.

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

Please describe how your state Flex Program is reaching out to non-traditional partners to support its work.

The Maine Flex Program works with the other groups that are influencing and monitoring changes in the healthcare environment specifically linked to payment and health plans.  Groups like the Maine Association of Health Plans, Healthcare Purchasers Alliance of Maine, and the Maine Chapter of Healthcare Financial Management Association (HFMA) are all important partners for Hospitals to access for information linked to healthcare finance. They invite these healthcare finance partners to participate in network meetings, promote trainings and educational opportunities that help to enhance CAH Hospitals staff aptitude for financial security.

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
(207) 287-5504

Planning & Research Associate since November 2017

Erica Dyer
Office Associate II, Maine
(207) 287-5524

Specialty Areas/Background

Reception, Contracts, and Reports

Office Associate since November 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, $1,560,000 (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.