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Minnesota Department of Health, Office of Rural Health and Primary Care

Top Flex Activities

Program Area: Support for Quality Improvement

Stratis Health and the Minnesota Hospital Association are leading a collaborative effort with the Minnesota Office of Rural Health and Primary Care (ORHPC), along with several successful mentor hospitals, to guide a cohort of 21 critical access hospitals (CAHs) through a journey to a "Culture of Excellence" that drives performance across all quality and patient safety topics. The critical role of leadership in building a culture underlies the expectation that participating hospital chief executive officers (CEOs) actively participate in the Culture of Excellence project. The Culture of Excellence program is therefore led in each hospital by the CEO, a Culture of Excellence champion, and an interdisciplinary Culture of Excellence team.

The Culture of Excellence program walks the participating hospitals through a local grassroots application of existing quality and patient safety resources and concepts such as customer experience, patient and family engagement, leadership support, board engagement, teamwork and communication, justice, and accountability. Key measures of success include Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results and Agency for Healthcare Research and Quality (AHRQ) Culture of Patient Safety surveys, and quality and patient measures specific to the local hospital. CAHs within this cohort conduct the AHRQ Culture of Patient Safety survey. Participants then examine survey results to identify areas to focus on and form workgroups to move focus areas forward. Participants have shared planned focus areas on monthly calls and will share learnings from activities they have tried.

Program Area: Support for Financial and Operational Improvement

The Minnesota Flex Program continues to distribute CAH Financial Indicator Reports (CAHFIR) along with supplemental and more current financial data to help CAHs target areas that represent challenges. The Minnesota Flex Program has identified lower performing hospitals that will continue to receive targeted support as needed, after establishing communications with individual CAHs to identify how the state Flex Program can best support their efforts to build sustainable operations.

This year, the Minnesota Flex Program continues to work on customized summary reports to help CAHs better understand their financial and operational strengths and weaknesses. Financial and operational trends will be evaluated and metrics will be developed to help analyze the larger macro CAH trends versus measure-level trends. Based on the 2016 CAH hospital listing of financially distressed hospitals, the Flex staff and the Minnesota Hospital Association are collaborating to provide commentary reports summarizing multiple data sources related to market, staffing, finances, and operations.

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

Population Health

The Minnesota Flex Program is working with a subcontractor to facilitate an Integrative Behavioral Health (IBH) project with cohorts of CAHs from around the state. Participating CAHs identify a behavioral health population to target in their own communities, as well as community partners with which to collaborate. Three cohorts of approximately five CAHs each have been selected to participate by use of an application process that identified those CAHs most ready to integrate mental and behavioral health services into their community based on variables such as leadership, collaborations, identification of a target population, workforce capacity, need, goals, and work plan. The interventions with each cohort include one year of assistance with business and clinical management processes for integrating mental and behavioral health services into hospital and primary care settings for the purpose of providing enhanced patient-centered care. CAHs that completed the process in year one and year two share tools and offer peer support for the CAHs that began in year three. Each cohort continues to share best practices among the whole group.

In addition to the three cohorts, starting in year four, the Integrated Behavioral Health Project expanded to include six CAHs from Wilderness Health, an ACO collaborative of hospitals in Northern Minnesota. These hospitals that participated in community-wide strategic planning are working to create healthy communities where there is no stigma of mental illness.

Technical assistance provided to the cohorts includes a variety of strategies including webinars on business and clinical management from subject matter experts, tools, best practices, lessons learned, resources, policy, and emerging trends, etc., followed by facilitated discussion with the subcontractor. Conference calls are used to offer feedback on activities as well as guidance on topics such as strategy implementation, leadership and sustainability, strategic planning, measurement, operations, processes, and outcomes. Evaluation is underway, including the administration of a Recommendation Adoption Progress (RAP) report, an evaluation tool that captures the degree to which activities have been implemented and services used by program participants.


Greater Northwest Emergency Medical Services (GNWEMS) and Stratis Health are leading a collaborative arrangement to facilitate the development of an emergency medical services (EMS) feedback form. The project’s objective is to establish a communication loop from pre-hospital patient interaction, to the local CAH emergency department, to the tertiary care center, back to the local emergency department (ED), and finally back to the initial pre-hospital EMS agency. This pilot project is focusing on trauma and stroke patients and will be expanded to include ST-elevation myocardial infarction (STEMI) and Sudden Cardiac Arrest. Since the start of the project, it has expanded to include hospitals and EMS agencies in the Southwest Region of Minnesota, doubling the number of participants.

In 2015-2016, the Minnesota Flex Program conducted a survey to assess the sustainability of rural EMS agencies. In response to the findings from that survey, the EMS Regulatory Board is conducting individual assessments of one rural ambulance service in each of Minnesota’s rural EMS regions. These surveys provide detailed assessments, recommendations and technical assistance to help improve the sustainability of rural ambulance services.

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

Minnesota continues to support its CAHs in quality reporting and quality improvement activities in order to provide rural Minnesota communities with the highest quality of care. By investing in activities such as patient safety, culture and population health, the Minnesota Flex Program and its partners are encouraging hospitals to work on initiatives that will support them in the transition to value-based care.

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

The Minnesota Flex Program encourages cohorts of hospitals to work together in projects such as those highlighted above. However, because most CAHs are parts of hospital systems or have historically established, well-run networks, the Minnesota Flex Program participation in network development or maintenance is not a high priority.

Please describe how your state Flex Program has enhanced its use of data in the past year.

As part of the Minnesota Flex Program’s contract, Stratis Health works with hospitals on improving how they abstract their data. Stratis Health also provides individualized technical assistance to each hospital for interpreting quality data and applying the knowledge for quality improvement activities.

The Minnesota Flex Program's financial and operational improvement work utilizes the Critical Access Hospital Measurement and Performance Assessment System (CAHMPAS), as well as other financial data supplied through the Minnesota Hospital Association. Along with the quality program contractors, Minnesota Flex provides individualized technical assistance to hospitals, helping them interpret and understand data reports.

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


Program Statistics

Type of Organization State Government
Staffing 2.1 FTEs
Number of CAHs 78
Website URL Organization Website

Flex Program Staff

Zora Radosevich
Flex Director, Minnesota
(651) 201-3859

 Flex Director since April 2018

Emma Distel
Flex Coordinator, Minnesota
(651) 201-3528

Flex Coordinator since November 2018

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

Specialty Areas / Background

Trauma system coordination

Craig Baarson
Reimbursement Fiscal Analyst, Minnesota
(651) 201-3840

Specialty Areas / Background

Reimbursement and finance

Rose Christensen
Office Administrative Assistant, Minnesota
(651) 201-3852

Office Administrative Assistant since October 2018

Anna Rodell
Research Analyst, Minnesota

Began in June 2019

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, $1,205,000 (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.