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New Hampshire Department of Health and Human Services - Division of Public Health Services, State Office of Rural Health

Top Flex Activities

Program Area: Support for Quality Improvement

The Flex Program’s Quality Improvement Coordinator directly provides timely education for abstracting and reporting Medicare Beneficiary Quality Improvement Project (MBQIP) measures on-site at the hospitals, along with resources tailored to individual hospital needs. Direct support also includes telephone coaching and email responses to in-the-moment questions. On-site education is often repeated as staff turns over.

For the MBQIP measures added for Flex fiscal year (FY) 2018, seven of the 13 critical access hospitals (CAHs) are engaged in individualized education on reporting the emergency department (ED) measures and gaining an understanding of the value of the new data for improving ED through-put for admitted patients. 

Most CAHs in New Hampshire have implemented antibiotic stewardship programs; for those in need of assistance, the state Flex Program is collaborating with the Hospital Improvement Innovation Network (HIIN), quality improvement organization (QIO) and the New Hampshire Healthcare-Associated Infections program to provide direct assistance. In addition, the program reimburses CAH pharmacists for the cost of obtaining the certification offered by the Society of Infectious Disease Pharmacists (SIDP).

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.

A smaller CAH (6-8 beds) located 11 miles from the Canadian border requested a review of their Emergency Department Transfer Communication (EDTC) data to assure they were collecting and reporting the data correctly and to identify any opportunities for improvement. Using the data reports provided by the state Flex Program, the hospital has made significant changes to their transfer communication forms. They also demonstrated excellent documentation of the ED services provided. This small CAH now offers its patients enhanced care through tele-ED and tele-behavioral health with state-of-the-art setups in designated ED rooms. Their performance in ED through-put measures is better than state and national benchmarks, and they are eager to report and monitor the Inpatient Quality Reporting (IQR)-ED data set.

Program Area: Support for Financial and Operational Improvement

During the FY 2017 program year, New Hampshire's Flex Program will be utilizing a subcontractor to address the top financial concerns identified by our hospitals. Specifically, the contractor will be providing revenue cycle management activities that may include contract management, denial management and charge capture opportunities. This work will be done in coordination with the New Hampshire Rural Health Coalition, a working group of CAH Chief Executive Officers (CEOs)/Presidents and the New Hampshire Foundation for Healthy Communities. Revenue cycle management improvement will be assessed using an evaluation tool in addition to the continued tracking of major financial indicators for each CAH.

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

The New Hampshire Flex financial improvement activities in this program year include charge capture effectiveness, which will help CAHs transition to value-based care by ensuring that they are coding appropriately for prevention activities and complex case management. 

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

Flex Program activities in New Hampshire are implemented through the Rural Health Coalition, which allows the program to share critical information, obtain feedback from CAH CEOs/Presidents and participate in shared ownership regarding the direction for Flex funding.

The Quality Improvement Coordinator in New Hampshire also participates in collaborative meetings of the New England Quality Innovation Network (QIN-QIO) and the HIIN to ensure that New Hampshire Flex is not duplicating efforts or putting funding toward an area that is being emphasized by another supporting organization.

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

The New Hampshire Flex Program collaborates with its peers in Maine, Vermont and Massachusetts to provide educational resources for CAH staff. Known as the New England Performance Improvement (NEPI) Network, the states work together in collaboration with the New England Rural Health Roundtable to maximize services by pooling a set amount of Flex funds from each state. NEPI provides access to:

  • Institute for Healthcare Improvement (IHI) Open School and Virtual Expeditions
  • Reimbursement for professional certifications in quality, patient safety, antibiotic stewardship, and others
  • Financial support for the Trauma Nurse Core Course and other relevant training

NEPI is open to changing the support provided based on the most pressing needs identified by the CAHs.

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

In the past year, the New Hampshire Flex Program assessed CAH performance through data analysis including CAH financial indicators as documented on the Critical Acces Hospital Measurement and Performance Assessment System (CAHMPAS) and the Flex Monitoring Team CAH Financial Indicators Reports (CAHFIR). Indicators used by the program include: total margin, operating margin, current ratio, days cash on hand, days in gross accounts receivable, days in net accounts receivable, salaries to net revenue, Medicare inpatient payer mix, debt service coverage and long-term debt to capitalization.

The plan for this and future years is to document these financial indicators annually, measure trends over time and compare the 2015 baseline indicators to state and national medians as well as CAHMPAS benchmarks.

Please share any resources or tools that you found useful in your state Flex Program's work this past year that you would recommend to your Flex Program colleagues.

The Crucial Conversations webinar was excellent. It’s a good overview and reminder that the conversations happening are not always just the issue at hand.

Program Statistics

Type of Organization State Government
Staffing 2.5 FTEs
Number of CAHs 13
Website URL Organization Website

Flex Program Staff

Alisa Druzba
State Office Director, New Hampshire
(603) 271-5934

Specialty Areas / Background

  • Primary care access
  • Primary care workforce development
  • Population health
  • Statewide health systems
  • Oral health
  • Logic models

State Office Director since May 2006

Alia Hayes
Flex Coordinator, New Hampshire
(603) 271-2286

Flex Coordinator since May 2017

Marie Wawrzyniak
Rural Health Quality Improvement Coordinator, New Hampshire
(603) 271-1093

Rural Health Quality Improvement Coordinator since August 2016

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.