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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 objectives in this area, the Missouri Flex Program has contracted with the Missouri Hospital Association (MHA) to offer technical assistance for the Medicare Beneficiary Quality Improvement Project (MBQIP), utilizing webinars, conference calls, in-person training, regional training, and one statewide training annually. 

MHA has built a dashboard for critical access hospitals (CAHs) that promotes MBQIP and utilizes quality data for improvement activities. Each hospital has the ability to look at aggregate performance as well as the most current performance averages for the state and nation on the dashboard. The data collected has been used to drive performance improvement in a variety of ways. Low performing hospitals are contacted in regards to the identified gaps and MHA works with them to help address best practice strategies. Furthermore, regional meetings are hosted and attendees actively participate and network with others who might be struggling in the same areas. Additionally, increased reporting for MBQIP measures has been the main focus and continuous improvement has helped increase the number of hospitals reporting on such measures. 

CAH Operational and Financial Improvement

The Missouri Flex Program has subcontracted to MHA to offer technical assistance in this area. Flex funds were used to support a CAH swing bed analysis performed by Stroudwater Associates (Stroudwater), which provided comprehensive, 24-hour access to a dedicated web application (Swing Bed Web Application) hosted and maintained by Stroudwater in support of a national CAH swing bed pilot project. All participating CAHs, as determined by MHA, registered for the web application and provided patient-level data to Stroudwater via the web application during a 12-month period. Additionally, MHA subcontracted with Stroudwater to evaluate participating CAHs' most recently filed Medicare Cost Report to identify opportunities to eliminate errors and omissions, resolve conflicts, review cost allocation methods, and identify operational and strategic initiatives and/or accounting practices to improve financial performance. CAHs were provided hospital assessment reports that included a description of the analysis, a summary of results, and prioritized recommendations.

The CAH Chief Executive Officer (CEO) Network meeting helps guide the financial and operational activities for a select cohort of hospitals in need of assistance.

CAH Population Health Improvement

The Missouri Flex Program contracts with MHA to conduct population health activities such as providing education and health prevention activities based on common community health issues identified, including developing and distributing chronic care management toolkits and working with participating CAHs to develop and implement strategies. In 2017, MHA developed a comprehensive population health assessment survey tool to help gauge where each hospital is in their transition to a value-based environment and will resurvey in 2020.

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. Missouri also participated in the Transition to Value Learning Collaborative through the National Rural Health Resource Center where CEOs completed a survey that provided them with results that wthey have started utilizing to help close those gaps identified around population health management.  

Innovative Model Development 

The Missouri Flex Program has subcontracted to MHA to offer technical assistance in this area. MHA is to develop and test innovative models related to social determinants of health, specifically transportation. MHA will collaborate with interested CAHs and external partners related to transportation. 

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

MHA 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)  
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.  Ms. Davenport is responsible for directing the overall planning and coordination of the activities within the State Office of Rural Health, 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. Ms. Davenport 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.  Ms. Davenport oversees eight staff and reports to the Division of Community and Public Health’s Deputy Director. 

Office Chief since December 2019.

Misty Dennis
Rural Health Coordinator, Missouri

Misty Dennis acts as the Rural Health Coordinator to provide support for rural health care issues, research findings, information dissemination and planning function, as well as, innovative approaches to the delivery of health care in rural areas.

Rural Health Coordinator since January 2020.

Barbara Brendel
Rural Health Manager, Missouri

Overall, Barbara has 32 years of public health experience.  For the past 7 years, Barbara was responsible for developing statewide infrastructure needs for a Centers for Disease Control and Prevention (CDC) Community Health Worker project.  Through partner consensus, three major areas were accomplished: 1) statewide curriculum implemented, 2) certification process established, and 3) Community Health Worker Association of Missouri established.  Barbara also has experience in developing contracts and grants.

Rural Health Manager since March 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, $1,009,121 (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.