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Missouri Department of Health and Senior Services - Office of Rural Health

Top Flex Activities

CAH Quality Improvement

In order to achieve the critical access hospitals (CAHs) quality improvement objectives, the Missouri Medicare Rural Hospital Flexibility (Flex) Program utilizes a contractor to provide technical assistance for the Medicare Beneficiary Quality Improvement Project (MBQIP), utilizing webinars, conference calls, site visits, in-person training, regional training, and one statewide training annually.

Missouri CAHs have access to a dashboard that promotes MBQIP and utilizes quality data for improvement activities. Each hospital has the ability to view aggregate performance as well as the most current performance averages for the state and nation on the dashboard. The data collected is used to drive performance improvement in a variety of ways. The Missouri Flex Program contacts and assists low performing hospitals in regards to the identified gaps and addresses best practice strategies. A swing bed benchmarking project provides CAHs with access to a web-based application supporting national CAH Swing Bed performance improvement. Through facilitated peer to peer discussions, CAH participants foster relationships and share best practices on Core MBQIP measures. Additionally, regional meetings are hosted and attendees actively participate and network with others who might be struggling in the same areas. The main focus is increased reporting for MBQIP measures and continuous improvement has helped increase the number of hospitals reporting on such measures.

CAH Operational and Financial Improvement

The Missouri Flex Program utilizes a contractor to offer operational and financial technical assistance. Utilizing the Flex Monitoring Team Financial Indicator Report, struggling CAHs are identified and provided targeted technical assistance. Trainings and webinars are provided on new payment and care delivery models, how to improve revenue management and processes, and board education and leadership. Billing and coding education is provided to improve the understanding, compliance, and identify areas of improvement and increased productivity.

CAH Population Health Improvement

The Missouri Flex Program utilizes a contractor to conduct population health activities, such as providing education and health prevention activities based on common community health issues identified and working with participating CAHs to develop and implement strategies. In 2020, a comprehensive population health assessment survey was conducted with all Missouri hospitals. The survey covered nine categories: leadership, patients and community, workforce, finance, data and technology, operations, legal/regulatory, outcomes, and policy/advocacy. The results were tabulated and mapped to a maturity scale comprised of five categories: Pre-Foundational 1, Pre-Foundational 2, Foundational, Proficient, and Transformational. Furthermore, additional individualized reports were developed indicating overall performance for each of the nine categories and identified each CAH’s position on the maturity scale. 

Results were shared with each hospital's leadership to help them better understand the necessary tools and resources, interventions, and targeted support that is needed to close the gaps identified. Key strategies were also developed to deploy, in relation to the category, where they landed on the population health maturity scale.  

Innovative Model Development 

The Missouri Flex Program utilized a contractor to offer technical assistance to CAHs to develop and test innovative models. An innovative model for transportation has been developed. The Telemedicine Innovative Model cohort has been established for the 2020-2021 grant year. 

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

The Missouri Flex Program hosts a CAH CEO network meeting annually. This forum is used to identify the needs of the CAHs and decide what activities the Missouri Flex Program should focus on. Additionally, three regional meetings are hosted in the spring and fall, and CAHs are also encouraged to attend the Annual Flex Meeting in August, which encompasses a variety of topics that include quality and financial improvement.

Program Statistics

Do you have any hospitals interested in converting to CAH status?:
Type of Organization State Government
Staffing (FTE) 1.72
Website Organization Website 
Number of CAHs 35

Flex Program Staff

Sara Davenport
Office Chief, Office of Rural Health and Primary Care, Missouri

Sara Davenport is the Office Chief for the Office of Rural Health and Primary Care (ORHPC). The Office Chief is the Project Director for all federal grants within ORHPC. The Office Chief is responsible for directing the overall planning and coordination of the activities within the State Office of Rural Health (SORH), Primary Care Office, and the Primary Care Resource Initiative for Missouri (PRIMO) programs, including the identification of program priorities, strategic planning, and performance management initiatives. This position has program management and decision-making authority, as well as policy setting, assessment, budget planning, and supervisory responsibilities. Key to this role is the integration of Missouri Office of Rural Health activities with other Federal and State funded initiatives to assure maximum impact of program funds/activities in rural areas. The Office Chief position oversees nine staff and reports to the Division of Community and Public Health’s Deputy Director.

Office Chief since November 2019

Barbara Brendel
Rural Health Manager, Missouri
(573) 526-2825

Barbara Brendel is the Rural Health Manager for the ORHPC. This position is responsible for assisting with the administration of the SORH, FLEX, and SHIP Grants and associated contracts. This position serves as the SORH director and ensures grant deliverables are met and adheres to all the grant requirements, including monitoring contract and budget compliance activities and coordinating funding proposals. This position assists in the preparation and dissemination to state legislatures and stakeholders the Health in Rural Missouri Biennial Report. The Rural Health Manager conducts liaison activities between the CAHs and Local Public Health Agencies (LPHAs) to ensure hospitals are involved in the community health needs assessment process. Key to this position is the technical assistance and direction provided on projected planning needs, and collaborates between federal, state and community entities to improve cooperation. This position provides information and technical assistance to rural counties regarding the availability of grants, loans, and other financial resources. This position initiates and maintains collaborative efforts between programs to avoid duplication of services, while furthering activities related to rural health care. The Rural Health Manager position supervises the Rural Health Coordinator position and reports to Office Chief.

Rural Health Manager since March 2020

Tiffany Taylor
Flex Coordinator, Missouri
(573) 751-6441

Flex Coordinator since August 2021

Misty Dennis
Rural Health Coordinator, Missouri
(573) 526-5978

Misty Dennis is the Rural Health Coordinator for the ORHPC. The Rural Health Coordinator provides support for rural health care issues, research findings, information dissemination and planning function, including innovative approaches to the delivery of health care in rural areas. Coordination with national initiatives and activities, and evaluation and dissemination of models that work is a major job responsibility. This position provides information and technical assistance to rural counties regarding the availability of grants, loans, and other financial resources. This position is responsible for implementing and monitoring the grant deliverables associated with the SORH, FLEX and Small Rural Hospital Improvement Program Grant (SHIP) programs and incorporates services, provides technical assistance, and develops planning strategies with nongovernmental, State, and Federal programs regarding rural health program participation. The Rural Health Coordinator reports to the Rural Health Manager.

Rural Health Coordinator since January 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.