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New Hampshire Department of Health and Human Services

Top Flex Activities

Program Area: Support for Quality Improvement

The New Hampshire Flex Program showed overall improvement in the critical access hospitals (CAHs) Medicare Beneficiary Quality Improvement Project (MBQIP) scores and in the number of measures reported. Efforts from the Flex Program included providing training and technical assistance directly at the hospital sites and having ongoing access to Flex Program staff for help-desk type reporting and data analysis questions.

Program Area: Support for Financial and Operational Improvement

During fiscal year (FY) 2017, the New Hampshire Flex Program used a contractor to address denials. The nine participating CAHs are in the midst of data transfer and each hospital will receive a report regarding their reasons for denials. A second phase of the program will begin in January 2019 and CAHs who did not participate previously will be allowed to join phase II.

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

New Hampshire CAHs have gained capacity in reporting data to the Centers for Medicare & Medicaid Services (CMS), which will allow them to participate in the hospital-based CMS reporting programs in the future. Current examples include the Hospital Inpatient and Outpatient Quality Reporting Programs (Hospital OQR) and Hospital Value-Based Purchasing (VBP). New Hampshire CAHs are also reporting electronic clinical quality measures (eCQMs) in order to participate in the Promoting Interoperability (PI) Program.

Each CAH has identified a quality improvement project based on their MBQIP data. If the projects meet program criteria, CAHs are provided stipends to implement their projects.

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 and obtain feedback from CAH chief executive officers (CEOs)/Presidents regarding the direction for Flex funding. The Rural Health Coalition meets at the Foundation for Healthy Communities and the New Hampshire Hospital Association, which allows the New Hampshire Flex Program to learn of current initiatives involving hospitals.

The Quality Improvement Coordinator in New Hampshire also participates in collaborative meetings of the New England Quality Improvement Network (QIN) - Quality Improvement Organization (QIO) and the Hospital Improvement Innovation Network (HIIN) to ensure that no duplicated efforts or funding put toward an area that is supported by another organization.

The Flex Coordinator participates in the New Hampshire Stroke Collaborative to stay informed of efforts to move toward a stroke system of care and keep New Hampshire CAHs informed of any information/activities that may be beneficial for them or affect them. The Flex Coordinator also attends the Trauma Medical Review Committee Meetings to stay updated on the Trauma System in New Hampshire and relay pertinent information to the CAHs.

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

The four New England States who participate in the Flex Program (New Hampshire, Maine, Vermont, Massachusetts) belong to the New England Performance Improvement Network (NEPI). This network allows the states to pool funding and provide access to certifications and training for CAH staff. NEPI participants share new resources and best practices around CAH engagement and education.

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

Custom MBQIP data reports are provided to the New Hampshire CAHs in order to easily identify opportunities for improvement. Custom reports for each CAH include Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data over time in run charts and HCAHPS data presented over time with comparisons to CAH state, CAH national, and national data. A unique dashboard report is provided to each CAH displaying OP-3 over time, OP-5 over time and an emergency department (ED) throughput graph showing OP-18, ED-1, and ED-2 over time. These dashboards, updated quarterly, easily show CAHs changes in their own performance and how their performance compares to peers. In addition, if a possible change is noted, the data may be provided in a run or control chart to assess improvement.

In the past year the New Hampshire Flex Program assessed CAH performance through data analysis including CAH financial indicators as documented on the Flex Monitoring Team's Critical Access Hospital Measurement and Performance Assessment System (CAHPMAS) and the Critical Access Hospital Financial Indicator Report (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 is to document these indicators annually, measure trends over time and compare the baseline indicators (2015) to state and national medians, as well as CAHMPAS benchmarks.

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


Program Statistics

Type of Organization State Government
Staffing 2.35 FTE
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.