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Massachusetts Department of Public Health, Office of Rural Health

Top Flex Activities

CAH Quality Improvement

In Fiscal Year (FY) 2021, the Massachusetts Flex Program (MA Flex) continues to build on past successes in the Medicare Beneficiary Quality Improvement Project (MBQIP) required core measure areas within the categories of patient safety, patient engagement, care transitions and outpatient measures, along with the additional MBQIP areas of adverse drug events, improvement in emergency department (ED) patient experience, and improvement in swing bed care.

Three quality improvement (QI) activities in FY 2021 include:

  1. In the areas of outpatient and inpatient core ED throughput measures, MA Flex will continue to work with Stroudwater Associates on process improvements that they originally identified in on-site critical access hospital (CAHED assessments performed in 2018. This effort will take place within the context of the Massachusetts Rural Hospital ED Leadership Network (3 CAHs, 3 SRHs, 2 satellite EDs). MA Flex and ED leadership will continue to review best practices for process improvement and to monitor the most effective evidence-based intervention(s) chosen by each facility, such as redesigning registration and/or triage processes, tracking of lab and radiology turn-around times that were implemented. Tracking ED throughput measures via Telligen reports will help to gauge improvement impact on issues that have been a long-standing challenge for all Massachusetts CAHs. This year MA Flex is working with Stroudwater Associates to provide an ED process improvement review focused specifically on behavioral health for at least 1 CAH.  Insights from this CAH-specific intensive will be shared with the group. Priority action items will be identified for all.  In addition, MA Flex will support at least one CAH with a large service area population of residents > 65 years in pursuing geriatric accreditation for the ED by the American College of Emergency Physicians (ACEP) program.  This CAH will be using SHIP funds for the educational pieces of this effort. The goal of this project is to improve both processes and care outcomes for geriatric patients in the ED
  2. In the area of additional patient safety concerns focusing on adverse drug events, MA Flex will be building on previous work done with the Institute for Safe Medication Practices (ISMP). In FY2020, the pharmacy director and quality director from 1 CAH participated in a two-day Virtual Medication Safety Intensive offered by ISMP and funded by MA Flex. In FY 2021, at least 2 additional CAHs will participate in a 5-week (1 day per week) Virtual Practitioner in Residence (PIR) Medication Safety Specialist Mentorship.  Through these efforts, MA Flex hopes to address the prevention of ADEs by ensuring that there is a well-trained medication safety specialist at each MA CAH and reviewing the status of medication errors over time. 
  3. For the Special Quality Improvement Project for FY2021, MA Flex is participating with Stroudwater Associates in the swing bed quality improvement effort.  This comes under the category of reporting and improving additional care transitions measures.  MA CAHs have been reporting swing bed data for some time via the Stroudwater portal first established during work with the University of Minnesota swing bed efforts.  Two MA CAHs are participating in this project, and both are focused on the measure Return to Acute Care within 30 days Post Discharge. 

CAH Operational and Financial Improvement

MA Flex will continue with the highly valued Massachusetts Rural Hospital CEO/CFO Forum – a collaboration with the Massachusetts Health and Hospital Association (MHA) and their Flex-funded partner Stroudwater Associates – as the key vehicle for improving the financial viability and operational effectiveness of Massachusetts CAHs. This continues to be the infrastructure within which Massachusetts CAHs (and a sole community hospital and Massachusetts small rural hospitals (SRHs) who participate in meetings) achieve results, with activities including benchmarking and analyzing their financial and revenue cycle health, learning up-to-date strategies for cost reporting, managing their relationship with their larger health systems, maximizing accountable care organization (ACO) and other alternative payment opportunities, maximizing swing beds, as well as aligning their hospital more closely with primary care physicians to improve the value basis of their care delivery. Stroudwater also brings in additional staff, as needed, to assist rural hospitals with data collection and evidence-based interventions. 

In previous grant years, Stroudwater has provided on-site financial and operational assessments to CAHs as well as feasibility analyses for the development of CAH-based rural health clinics (RHCs), which is a model that is still relatively new for Massachusetts. The measurement of the network and project impact is both qualitative and quantitative. In a recent survey of what was most valuable about the CEO/CFO Forum, a summary of multiple participant comments included: “sustains the network of small hospitals, critical thinking and direction regarding regulatory changes affecting our hospitals and various operational approaches, networking with other CAHs and agencies, successes and failures at other CAHs or SRHs, regular contact and discussion about new and emerging issues, networking on operational and strategic issues, meeting with colleagues, review of market updates and what projects each hospital is working on, and Massachusetts Health and Hospital Association (MHA) reports are extremely valuable.” All CAHs rated their on-site financial and operational assessments and their RHC feasibility analyses among their most valued projects supported by the network. The top interests for the future included RHC review and improvement, telehealth, and additional cost report analysis. MA Flex also tracks the Flex Monitoring Team’s 12 CAH Financial Indicators, as well as Stroudwater’s financial and revenue cycle indicators over time and offers extra assistance to the CAH with a history of the most financial distress. In FY2020, and so far for FY2021, this group continues to meet virtually and more frequently than the pre-pandemic quarterly in-person meetings.

In FY2020, Stroudwater brought a chargemaster review and cost report education to 1 CAH and an analysis and planning framework for reviewing the care delivery spectrum at another CAH. For FY 2021, MA Flex is continuing financial and revenue cycle data sharing and educational sessions with Stroudwater Associates, including navigating the pandemic’s impact on finances and service delivery with CEO/CFO Forum participants. Focused work will include RHC contract reviews for 2 CAHs,). The CEO/CFO Forum RHC work continues to coincide with the innovative models section that is focused on quality and compliance.  In addition, CAHs continue to access capacity-building certifications through their New England Rural Hospital Performance Improvement (NEPI) network, which focuses on strengthening capabilities in the ED.  FY 2021 ED-centered capacity building continues to include hands-on pediatric trauma training by the Boston Medical Center Community Outreach Mobile Educational Training (COMET) Program and Trauma Nurse Core Course (TNCC) training.

Rural Emergency Medical Services (EMS) Improvement

In the area of rural EMS improvement, MA Flex is pursuing the following activities:  

1. For rural EMS agency operational improvement, MA Flex hopes to assess the financial distress level of selected rural EMS agencies including utilizing tools provided by TASC.  The ability to do this is heavily dependent on the staffing and bandwidth of existing rural EMS agencies and OEMS regional coordinators at this juncture in the pandemic.

Innovative Model Development

In the area of innovative model development, MA Flex is pursuing the following activities:

  1. Supporting CAHs in creating compliant and sustainable hospital-based RHCs, a model relatively new to their state. Financial and operational assessment of RHCs are addressed under the financial and operational program area, but this work focuses on ongoing and broader support for compliance and quality.
  2. Supporting the development of additional comprehensive and compliant telemedicine programs at CAHs, as true telemedicine reimbursement parity and other accessibility issues are still being legislatively hammered out in Massachusetts. This work will build on insights gained from a state office of rural health (SORH) supported telemedicine survey of rural providers in Massachusetts. These models were chosen in order to allow Massachusetts CAHs to strengthen their connection with primary care service delivery in an effort to achieve more value-based care and optimize financial and operational resources to meet the healthcare requirements of the most needy of Massachusetts rural populations. MA Flex will work with Massachusetts SORH to assure that CAHs and CAH-based RHCs get the QI, billing and coding, and compliance support that they need to build sustainable RHCs. Similarly, MA Flex will work with Massachusetts SORH to bring telemedicine information, resources, and technical assistance to MA CAHs and SRHs as they seek to establish more robust and sustainable telemedicine programs at their facilities. Rural-relevant healthcare models in general have been new for Massachusetts and typically brought into the state by the SORH and Flex programs. As a result, state policy guidelines and regulatory or financing adjustments for these models are needed and take time and effort to be developed. Telemedicine reimbursement is still limited in Massachusetts and credentialing issues continue to be of concern. MA Flex and SORH will continue to work with the Massachusetts Health and Hospital Association and state agencies to build an even deeper understanding of how essential these models are for improving access to health care services for the more isolated communities in their state. Success will be measured by numbers of organizations implementing these identified models and their sub-features, participation in the Center for Medicare and Medicaid (CMS) or other relevant evaluation programs, and by establishing key baseline measures and tracking improvements over time.

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

The Massachusetts Flex Program continues to use ongoing rural hospital networks as the infrastructure for accomplishing projects and interventions. Networks link healthcare professionals with similar roles in their hospital organizations with MA Flex and other expertise. These networks include the MA Rural Hospital Quality Network, a collaboration between MA Flex, QI Leadership at rural hospitals and the MA Quality Innovation Network-Quality Improvement Organization (QIN-QIO), Healthcentric Advisors and the MA DPH Healthcare Acquired Infections/Antibiotic Resistance Program, and the MA Rural Hospital CEO/CFO Forum, a collaboration between MA Flex, rural hospital leadership, the MA Health and Hospital Association (MHA) and Stroudwater Associates. In addition to these long-standing networks, more recently the MA Flex Program developed a Massachusetts Rural Hospital Emergency Department Leadership Network  (and is exploring a new partnership with the Massachusetts Association of Emergency Physicians for it), which also includes leaders from rural Satellite Emergency Facilities (SEFs) in geographic areas where they have lost inpatient rural facilities. MA Flex also maintains an ad-hoc version of the previously more active Massachusetts Rural Hospital Pharmacy Network, in collaboration with rural hospital pharmacists and the Institute for Safe Medication Practices (ISMP). MA Flex also participates in the four-state New England Rural Hospital Performance Improvement (NEPI) Network, a collaboration between the Maine, New Hampshire, Vermont, and Massachusetts Flex programs and the New England Rural Health Association (NERHA) which contracts with the Institute for Healthcare Improvement (IHI) and others to support rural hospital capacity building. 

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

MA Flex participates in QI and financial and operational capacity building via the partnership of the New England Rural Hospital Performance Improvement (NEPI) Network. This network is a collaboration with the New England Rural Health Association (NERHA) and the four Flex programs in New England (Massachusetts, Maine, New Hampshire, and Vermont). Through this cross-state collaboration, they are able to contract with other entities and offer joint training opportunities that hopefully create some economies of scale and benefit rural hospitals throughout northern New England. For example, through this collaboration, they have an agreement with the IHI to offer modular online QI training via the IHI Open School and selected virtual programs that are composed of a series of focused webinars and/or telephone coaching. In addition, they offer QI professional certifications such as Certified Professional in Patient Safety (CPPS), Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Health Care Risk Management (CPHRM), and CIC Certification in Infection Prevention and Control. NEPI also offers the Emergency Nurse Association (ENA) Trauma Nursing Core Course (TNCC) and some of them have also offered the Emergency Nurse Pediatric Course (ENPC) via this collaborative. Resources are limited for these opportunities. Pooled NEPI funds also allow them to provide periodically updated graphically designed joint promotional materials to use with our hospitals in communicating these rural hospital capacity-building opportunities, which saves time, money, and presents an attractive joint/regional identity and support system. Each state also pursues one state-specific capacity-building project or strategy within the collaborative and all states benefit from new ideas and concerns shared with the group. MA Flex currently is pursuing a state-specific strategy of strengthening the Massachusetts Rural Emergency Department/Trauma Response capacity and as part of that is hoping to implement American Psychiatric Nurse Association online behavioral health training – an idea brought to the group by the New Hampshire Flex Program.

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

Non-traditional partners for MA Flex include having the opportunity to get more deeply involved with EMS partners than in the past (including with the MA DPH EMS for Children program) including having more direct contact with individual rural EMS agencies vs. via their oversight organizations. Through the MA Rural Emergency Department Leadership Network, MA Flex worked with the MA Tele-SANE (Sexual Assault Nurse Examiners) program which builds on previous work done with the MA DPH Rural Sexual and Domestic Violence Program and rurally located community-based sexual and domestic violence organizations. They continue to reach out to other non-traditional partners through our network collaborations and have worked with universities.

Program Statistics

Do you have any hospitals interested in converting to CAH status?:
Type of Organization State Government
Staffing (FTE) 1
Website Organization Website
Number of CAHs 3

Flex Program Staff

Cathleen McElligott
State Office Director, Massachusetts
(617) 695-7421
Ronnie Rom
Flex/SHIP Coordinator, Massachusetts
(617) 549-6312

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.