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North Carolina Office of Rural Health

Top Flex Activities

Program Area: Support for Quality Improvement

The North Carolina Flex Program has created a Quality Improvement (QI) Collaborative in which critical access hospitals (CAHs) can participate. The QI Collaborative meets quarterly and gives hospital staff a chance to network, share best practices, and identify opportunities for improvement. In addition, the quality improvement specialist meets individually with each of the 20 hospitals in the state.

A dashboard is displayed on the North Carolina Hospital Association website for hospitals to keep track of their own quality performance as well as the entire cohort of CAHs. Medicare Beneficiary Quality Improvement Project (MBQIP) reports are reviewed as they are released and high performing hospitals are identified for each area. Monthly coaching calls are offered to assist hospitals with reporting and improving outcomes.

Program Area: Support for Financial and Operational Improvement

The North Carolina Flex Program has created a Financial/Operational Learning and Action Network (LAN) in which CAHs can participate. The LAN meets quarterly and gives hospitals a chance to network, share best practices and identify opportunities for improvement. The contractors have individual engagements planned for 2019 with at least three hospitals that can benefit from specific analysis to their operations and finances.

The Flex Financial and Operational Improvement (FOI) contractor, Stroudwater Associates, has created a Tableau interactive dataset with the hospitals financial and operational measures. This dataset is reported quarterly to the North Carolina Hospital Association. At each quarterly meeting, the LAN discusses the dataset and when high performers are identified, the hospitals share their best practices and are often invited to present at future meetings. The contractors also collect data on swing bed outcomes as a pilot program to show value-based care in the CAH setting.

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

The North Carolina Flex Program conducts a Population Health Needs Assessment each year by reviewing community health needs assessments (CHNAs) for each hospital. These CHNAs have identified mental/behavioral health as a top priority for almost all hospitals, so several initiatives have been created to assist hospitals in this area. Mental Health First Aid (MHFA) trainings have been offered onsite at interested CAHs.

Please provide information about Collaboration/Shared Services 

The North Carolina Flex Program also assists in connecting hospitals to the North Carolina Statewide Telepsychiatry Program (NC-STeP), which helps hospital emergency departments (ED) gain access to psychiatrists who can assess and create a care plan for behavioral health patients. In the upcoming year, the North Carolina office will be implementing a planning grant for a paramedicine program in Clay and Graham counties to address the needs of high utilization of EDs and to monitor chronic care for patients in these rural counties.

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

The North Carolina Department of Health and Human Services (DHHS) has submitted an 1115 Waiver to transform the state's Medicaid Program. To assist CAHs during this transition, the North Carolina Flex Program has scheduled meetings with CAHs that center around Medicaid transformation and best practices for CAHs' in value-based care. In addition, discussions are facilitated at quarterly LAN meetings around changes to Medicare, private insurance markets and ways that CAHs can prepare for changes to payment and care models.

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

As mentioned above, there are collaboratives that meet quarterly for QI and Financial/Operational Improvement. The North Carolina Statewide Telepsychiatry Program, which is a state-funded program, has participation from most North Carolina CAHs and assists hospital EDs in caring for behavioral health patients.

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

At the last quarterly meeting, North Carolina CAHs met briefly with South Carolina CAHs for a combined meeting to discuss market updates. This meeting was well received and it is likely that future collaborations will take place between the North Carolina and South Carolina State Offices of Rural Health (SORH).

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

The North Carolina Flex Program collects data from the Flex Monitoring Team (FMT) and discusses any trends with hospitals. The finance/operations contractor also tracks data and presents this at the quarterly meetings for discussion as well as remediation. When needed, the individual hospitals can get support to help with operational changes to help with financial outcomes.

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


Program Statistics

Type of Organization State Government
Staffing 2.0 FTE
Number of CAHs 20
Website URL Organization Website

Flex Program Staff

Maggie Sauer
State Office Director, North Carolina

State Office Director since June 2017

Nick Galvez
Flex Coordinator, North Carolina
(919) 527-6467

Flex Coordinator since June 2018

Renee Clark
Rural Hospital Specialist

Rural Hospital Specialist since November 2018

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.