Minnesota State Flex Profile

Top Flex Activities

Program Area: Support for Quality Improvement: 

The bulk of quality improvement activity is subcontracted to a quality improvement organization with assistance from the Minnesota Hospital Association (MHA). The subcontractor provides the following services under their Minnesota Flex contract:

  • During year one of this three-year grant cycle, quality improvement consultants make site visits to nearly all critical access hospitals (CAHs) to help CAH staff understand quality data reports and connect them to relevant tools and resources
  • Hold quarterly meetings by phone to support quality improvement and patient safety
  • Provide a single point of contact to respond to questions and assist CAHs in navigating reporting processes for the Medicare Beneficiary Quality Improvement Project (MBQIP) and the Minnesota State Quality Reporting Measure System (SQRMS)
  • Provide individual outreach to CAHs as needed, with a priority on those not consistently reporting required MBQIP measures
  • Convene and facilitate reporting updates and networking sessions
  • Provide educational webinars
  • Establish and convene the Minnesota CAH Quality Advisory Group, which includes representation from the Minnesota Department of Health, the University of Minnesota School of Public Health, the American Heart Association, Minnesota Hospital Association, Minnesota Alliance for Patient Safety, several CAHs, one tertiary hospital and the National Rural Health Resource Center
  • During year two of the three-year grant period, convene meetings of cohorts of hospitals with a focus on Time Critical Care Diagnoses and Culture of Excellence

The Flex Program Coordinator offers mock survey assistance to CAHs upon request. The Flex Coordinator has developed a good understanding of the Conditions of Participation (CoP) for CAHs, and fields many questions by email and phone. To strengthen that resource, the Flex Coordinator has nurtured a positive relationship with Minnesota State Survey staff, who willingly serve as a consultant. About once a year (depending on the workload of the survey staff), the Flex team arranges a statewide phone call where CAH staff can hear from the State Survey Staff about the most common findings on CAH surveys for that year, receive CMS CoP updates and pose their questions directly to the survey staff.

Please share a success story about reporting quality data or using quality data to help Critical Access Hospitals (CAHs) in your state improve patient care: 

Using Flex funds to support quality improvement consultants in their work to make one-on-one contact through site visits with most of the 78 CAHs was well worth the time, effort and cost. Participating CAHs eagerly accepted the support, received personalized technical assistance and were able to tie their reporting efforts to planning for quality improvement initiatives.

Program Area: Support for Financial and Operational Improvement: 

The Minnesota Flex Program has subcontracted with MHA to:

  • Identify more in-depth financial and operational strengths and problems based on trends or issues identified through CAH Financial Indicator Reports (CAHFIR) along with FY 2014 commentary reports which provide comparison data on financial, staffing and utilization data.
  • Produce an annual charge comparison benchmarks report for CAHs to support revenue cycle improvement, which ensures appropriate pricing levels. MHA began planning and development work to create the charge comparison reports based on hospital discharge data collected from hospitals. The reports are based on previous work initiated with several hospitals that have requested this type of customized information in the past

In addition to the above work with the MHA, the Flex Program Financial Analyst provides one-on-one TA with CAHs, particularly those with specific financial concerns. The analyst performs economic impact studies for CAHs upon request and performs rural health clinic mock surveys upon request.

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

Integrated Behavioral Health (IBH)

Minnesota Flex has subcontracted to provide targeted technical assistance to a cohort of CAHs that are ready to begin integrating behavioral health services into primary care. Each participating CAH (both year one and year two of this grant cycle) is creating its own targeted population and targeted activity and planning with the assistance of the IBH project for improving access to behavioral health services in their CAH service area.

Emergency Medical Services (EMS)

In collaboration with multiple agencies and offices at the Minnesota Department of Health (MDH), during year one of this grant cycle, Minnesota Flex created a survey to assess EMS needs in the areas of EMS sustainability and time-critical diagnoses response. Minnesota received input from multiple stakeholders and made an intensive effort to encourage survey response from all rural EMS agencies in Minnesota. With consistent phone and in-person follow-up once the survey was launched, there was a high response rate from rural EMS agencies. Currently, Minnesota is analyzing the responses. By the end of January 2017, Minnesota will publish the results of the survey and will begin work on recommendations based on this survey and the results of an EMS meeting that resulted in recommendations for EMS sustainability.

Please provide information about Collaboration/Shared Services (specifically connected to population health management): 

Minnesota Flex collaborates in nearly all of the activities for CAHs. In the area of Quality Improvement, Minnesota works with Stratis Health (QIO) and MHA to provide technical assistance to CAHs and to analyze improvement and areas of need for improvement. In the area of Finance and Operations, Minnesota works closely with MHA for the same reasons, as well. And in the area of population health management, Minnesota collaborates with others to achieve results. In the IBH project, Minnesota subcontracted to provide technical assistance to CAHs. As part of that project, participating CAHs are expected to form working collaborations with the appropriate organizations in their service area in order to achieve their objectives; a variety of organizations are included in those collaborations, depending on the specific objectives of each participating CAH. In the area of EMS sustainability, collaborative partners are the MDH Heart Disease and Stroke Unit, the MDH Injury and Violence Prevention Unit, the Minnesota State Trauma System and the MDH Office of Emergency Preparedness; outside of MDH, collaborating partners are the Emergency Medical Services Regulatory Board and the Minnesota Ambulance Association.

Both the QI and IBH projects have advisory committees made up of interested parties outside of the Office of Rural Health and Primary Care (ORHPC)/Flex Program who are experts in their respective areas. Furthermore, the Flex Program in Minnesota has a Flex Advisory Committee that advises the Flex Coordinator on Flex grant activity. That committee has representatives from CAHs, rural providers, EMS, Finance, MHA, Stratis Health, federal congressional offices and others.

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

The MHA, with participation of CAHs and the Minnesota ORHPC, completed a demonstration project on anticipated effects of transitioning to a Medicare value-based purchasing program. The demonstration has the potential to transform into an adoption of a mandatory value-based purchasing (VBP) program for CAHs. CAHs that submitted data will receive a trends analysis report. CAHs will not receive the impact analysis report. These results are based on the latest available VBP data, which use different baseline and performance date ranges than the actual FY 2017. This demonstration project provided CAHs with an analysis showing their current cost-based reimbursement compared with the potential financial impact if they had to move back to a PPS reimbursement system. This analysis was meant to show that potential federal changes to the CAH program could severely impact the CAH’s financial viability. These reports were also intended to encourage CAHs to look for ways to streamline their operations.

Minnesota Flex presented the findings of an MHA CAH Payment Reform task force that evaluated options to sustain cost-based reimbursement at the Minnesota Rural Health Conference. The two recommendations approved by MHA membership were to encourage the Centers for Medicare & Medicaid Services (CMS) to evaluate: 1. Moving CAHs to a value-based purchasing model, and 2. Implementing a readmissions program. These recommendations would put CAHs on par with prospective payment system (PPS) hospitals to better justify their reimbursement.

Please provide information about network activities in your state to support Flex Program activities (such as financial improvement networks, CAH quality networks, operational improvement with CEOs or EHR workgroups): 

The Minnesota Flex Program Financial Analyst participates as a consultant on monthly calls with Minnesota Department of Human Services. Participants on the call are rural health clinics (RHCs), focusing on billing processes to receive the full PPS rate. Minnesota currently has 87 RHCs, and almost all of them are provider-based attached to a CAH. Minnesota has approximately 33 CAHs with RHCs. Most of the CAHs with RHCs participate on this call. 

The Flex Coordinator manages a Google Group called CAH Talk for CAH clinical leaders. This online networking has proven to be very popular with Directors of Nursing, Quality Directors and other clinical staff. They can post questions asking for advice from each other, share best practices, policies and procedures, share resources, etc. It provides CAH clinical leaders easy access to peers throughout the state. Additionally, it frees up time for the Flex Coordinator who might otherwise be fielding their questions and spending a lot of time seeking answers or resources that they can now easily get from one another. The Flex Coordinator does not post on this group except in rare circumstances where there might be something posted that is misleading or needs further explanation, or if a question is directed directly at the coordinator.

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

Minnesota has begun meeting in person or by phone from time to time with other Flex Programs in the upper Midwest, crossing borders of National Organization of State Offices of Rural Health (NOSORH) regions. The Flex Coordinators from Minnesota, Wisconsin, North Dakota, South Dakota, Iowa, Nebraska and Kansas have agreed to meet from time to time to share challenges and success stories. All are Midwest states with a high number of CAHs.

From the last Flex Program year, please describe a best practice you would like to share with other states: 

Subcontracts with Quality Consultants who made site visits to nearly every CAH in the state and followed up with phone calls, and providing access to webinars and in-person training resulted in CAHs enthusiastically participating in MBQIP, including taking the step to use their quality data to plan for quality improvement initiatives.

Program Statistics

What type of organization is your Flex office housed in?: 
State Government
What is the number of full time employees (FTE) in your Flex office?: 
How many CAHs are in your state?: 
Do you have any hospitals interested in converting to CAH status?: 

Additional Information

Flex Program Staff

Mark Schoenbaum
State Office Director, Minnesota
(651) 201-3859

Specialty Areas / Background

  • Grants development and management
  • Project management
  • Policy research and analysis
  • Staff leadership

State Office Director since 2005

Tim Held
Rural Health System Development Unit Supervisor/Deputy Director, Minnesota
(651) 201-3868

Specialty Areas / Background

Trauma system coordination

Judy Bergh
Flex Coordinator, Minnesota
(651) 201-3843

Specialty Areas / Background

  • Grant writing and grant management
  • Project management
  • Health education in maternal/child health and adolescent health

Flex Coordinator since January 2007

Cindy LaMere
Office Administrative Assistant, Minnesota
(651) 201-3852

Specialty Areas / Background

  • Flex program support
  • Grants management support
Craig Baarson
Reimbursement Fiscal Analyst, Minnesota
(651) 201-3840

Specialty Areas / Background

Reimbursement and finance

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.