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Maine Rural Health and Primary Care Program

Top Flex Activities

Program Area: Support for Quality Improvement

Maine’s Flex Program brings together networks of critical access hospital (CAH) staff from all 16 CAHs in the state and measures activities through the Medicare Beneficiary Quality Improvement Project (MBQIP) and other publicly available quality data, as well as through survey instruments.

  • The Maine CAH Chief Executive Officer (CEO) Network provides overall strategic direction to the Flex Program.
  • The Maine CAH Chief Nursing Officer (CNO) Network serves as a workgroup to share best practices and learning opportunities as well as provide strategic direction to the Maine CAH Nurse Managers.
  • The Maine CAH Quality Improvement (QI) Directors Network meets quarterly.

All 16 hospitals participate in a benchmarking project to identify MBQIP measures, particularly Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, that network members agree to address at their individual facilities. CAHs work as a group to identify best practices for impact and report back on successes and challenges.

Through participation in the New England Performance Improvement (NEPI) Network, a collaboration of Flex Programs in Maine, New Hampshire, Vermont, and Massachusetts, Maine CAH staff have free access to various offerings from the Institute for Healthcare Improvement (IHI), including IHI Open School and Expeditions. Also through NEPI, Maine CAH staff are able, on a limited basis, to pursue free certification programs to become either a Certified Professional in Patient Safety (CPPS) or Certified Professional in Healthcare Risk Management (CPHRM).

In 2014, the Maine Flex Program began bringing together the Maine CAH Chief Financial Officers (CFOs). In collaboration with the Maine Hospital Association, the agendas have primarily focused on cost reports and chargemaster review. This collaboration meets four times per year.

Program Area: Support for Financial and Operational Improvement

The objective of the Maine CAH CFO Network objective is to bring together CFOs to identify financial indicators that the group can address as a whole and at their individual facilities, leading to improvement. Activity and progress towards goals are measured through iVantage’s Hospital Strength Index Reports, the Flex Monitoring Team (FMT) CAH Financial Indicators Reports (CAH FIR) and other current data provided by the hospitals themselves. Health care consultants with broad expertise in areas such as revenue cycle management and chargemaster review attend CFO Network meetings and provide guidance and education to the group regarding best practices to improve financial performance.

Since its establishment in fiscal year (FY) 2012, this network has been slow to identify measures to address as the group works to provide more current data than what is publicly available. To support operational performance at Maine CAHs, the Maine CAH Nurse Manager Network serves to bring together mid-level managers to share best practices, network, and learn operational improvement techniques from one another, as well as leading experts in this work in Maine and beyond.

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

The Maine Emergency Medical Service (EMS) Trauma System project provides guidance to CAHs and other rural emergency care providers with a statewide trauma system plan, technical assistance program, clinical consensus guidelines for patient care and transfer, and the development and implementation of trauma care performance measures. Maine Flex funds also supported the development of a community paramedicine (CP) program with the goals of better integrating EMS and community health resources in rural areas to fill gaps in advanced and basic life support EMS coverage and addressing other community health and medical gaps. In 2017, the Program started providing training across the State of Maine for the Stop the Bleed Program, these trainings have reached across all areas of our state. Since that time the group has met, it's re-named itself the Maine Stroke Alliance (Alliance) and established a mission statement as follows: “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.”

Please provide information about Collaboration/Shared Services 

In February 2017, a group of stakeholders from Maine EMS, Maine Centers for Disease Control, the Rural Health and Primary Care (RHPC) Program, the American Heart Association, Maine Medical Center, LifeFlight of Maine, Eastern Maine Medical Center, Pen Bay Medical Center, Maine General Medical Center and Maine Cardio Health Council/Medical Care Development met for the first time to discuss stroke readiness in Maine. The goal to create a coordinated system to deliver the right patient to the right place in the right amount of time was quickly established and the necessity to obtain buy-in from all stakeholders was identified. The group agreed to meet quarterly and establish sub-groups to work on projects between meetings as necessary.

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

The Maine Flex Program works with the CAHs in a network coalition to assist with the transition to value-based purchasing. CAHs are provided with individualized portfolios in regards to the Hospitals Strength Index Performance Report.

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

The Maine Flex Program brings together various networks including a CEO Network, CNO Network, 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 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:

  • IHI Open School and Virtual Expeditions;
  • reimbursement for professional certifications in quality, patient safety, antibiotic stewardship, and others;
  • and 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 has enhanced its use of data in the past year.

The Maine Rural Health Program utilizes its data for the CAHs Quality Improvement, the emergency department transfer communication (EDTC) and HCAHPS.

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


Program Statistics

Type of Organization State Government
Staffing 4.0 FTEs
Number of CAHs 16
Website URL Organization Website

Flex Program Staff

Nicole Breton
State Office Director, Maine
(207) 287-5427

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

Flex Coordinator since July 2018

Merica Tripp
Planning & Research Associate II

Planning & Research Associate since November 2017

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, $1,100,000 (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.