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Oregon Office of Rural Health

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CAH Quality Improvement

During Fiscal Year (FY) 20, the Oregon Office of Rural Health (ORH) continues to prioritize improved reporting by critical access hospitals (CAHs) under the Medicare Beneficiary Quality Improvement Project (MBQIP), while also engaging CAHs to emphasize quality improvement activities.   

For the fifth consecutive year, ORH continues to identify MBQIP Top Performing Hospitals under each of the MBQIP domains. Each year, those high performing CAHs that have consistently reported and whose rates fall at or above the state and national averages in each given domain are recognized. In addition, ORH awards one CAH as an “Overall Top Performer” (for all MBQIP domains) and one CAH as “Most Improved.” These CAHs and their Quality Officers are recognized throughout the state and at the Annual Oregon Rural Health Conference. They are also awarded $5,000 to implement a quality improvement project at their facility and have the following year to implement it. Their final reporting requirement is to showcase their project and results via a poster board presentation which is displayed at the Annual Oregon Rural Health Conference.

In FY20 ORH is also supporting CAHs in learning techniques to apply Lean Six Sigma practices into their quality improvement efforts and throughout their hospitals. This training is provided by Sigma Med Solutions through its Regional Rapid Improvement Learning Collaborative.

Additionally, FY20 marks the third year in which ORH is supporting CAHs to implement and/or sustain antibiotic stewardship programs (ASPs) by offering subscriptions to the University of Washington’s Tele-Antimicrobial Stewardship Program (UW-TASP). This program offers weekly didactic/ECHO-based sessions and access to a multitude of toolkits and other resources to assist hospitals with their ASPs.

ORH supports CAHs to improve the patient experience by offering continued programming for Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) improvements. For FY20, in addition to ongoing technical assistance, ORH will:

  • Provide onsite assessments and technical assistance to two CAHs via the Ignite the Patient Experience by Custom Learning Systems; and
  • Identify and publicly recognize the HCAHPS Top Performing CAH based on HCAHPS data results. Additionally, they will award that CAH quality officer a scholarship to attend the Institute for Healthcare Improvement (IHI) National Forum on Quality Improvement. 

CAH Operational and Financial Improvement

For FY20, ORH is employing the following to target strategic financial and operational improvement:

  • Continued use of CAH financial indicator and service line analysis and reporting.
  • Continued analysis of CAH community benefit reporting and spending to promote the community benefit impact of CAHs.
  • Coordinate the 2020 Rural and Frontier Listening Tour (RFLT) to convene stakeholders in a discussion of current challenges and to encourage partner collaboration to address solutions. This work will result in a report to be shared with Oregon’s state and federal delegation, among other stakeholders and also guide future work for ORH. The last RFLT, for example, resulted in implementing a mentoring program for nurses in Oregon CAHs.
  • Continue to provide finance and operational assistance to CAH-owned clinics to address their highest-rated challenges including staff and leadership training, assessment and assistance with transitions to alternative payment models, and quality improvement and technical assistance for regulatory compliance.

Additional activities focus on operational improvement for CAHs including supporting board training due to the high turnover of both CAH board members and leadership as well as continuing education support for CAH IT staff and directors.

CAH Population Health Improvement (optional, report if you have included in your work plan)

In order to provide customized, current analysis and reporting on community and service area health, ORH’s Data/Geographic Information System (GIS) Analyst purchases 12 datasets annually, and acquires more than two dozen others at no cost. The resulting ORH Primary Care Database contains the most comprehensive demographic and health status information for all rural areas in Oregon at the ZIP code level. These data are the source of the six-page Primary Care Service Area profiles, which have the latest ZIP code and county-level information on demographics, socioeconomics, vital statistics, maternity characteristics, mortality, health risk factors, and providers and primary care supply and demand numbers for all rural communities in Oregon. A sample of the current Service Area Profile and instructions for how to request customized profiles is available online. 

ORH produces the Areas of Unmet Health Care Needs (AUHCN) in Rural Oregon Report annually to measure access to primary physical, mental, and oral health care. The report is available on the ORH website.

In FY18, ORH created an interactive map of all of the most current community health needs assessments (CHNAs) and community health improvement plans (CHIPs) by county for Oregon's non-profit hospitals, local public health authorities (LPHAs), and coordinated care organizations (CCOs). The intent is to help interested parties easily find and use all of the documents for their area. ORH continues to update the information in the interactive map annually.

Within these reports, 96% of CAH CHNAs identified their aging populations as vulnerable. In FY20, ORH will coordinate a CAH-centered Forum on Aging in Rural Oregon to connect CAHs with subject matter experts as well as state and local partners to collaborate on ways to address rural aging community health needs.

Rural Emergency Medical Services (EMS) Improvement (optional, report if you have included in your work plan)

ORH partners closely with Oregon Health Authority’s (OHA) emergency medical agencies trauma systems (EMS/TS) to assess rural EMS priority challenges and to collaboratively address needs, including disparities in care. The FY18 Flex EMS Supplement Award funded a study of the differences between high and low-functioning agencies. As a result, action planning is underway. In FY20, ORH will continue to partner with OHA EMS/TS to update the licensure survey and will use this data annually to measure agency operational vulnerability progress and resource needs. ORH will also provide billing and reimbursement training for low-performing agencies to help them increase revenue and maintain operational stability.

Additionally, ORH is providing support for the Medical Director Forum and a scholarship for an EMS provider to attend the National Rural EMS and Care Conference to provide staff development opportunities to rural and frontier EMS agencies that would not otherwise have access to such training.

Further, ORH continues to build partner networks with EMS-focused organizations across the state such as the Oregon State Ambulance Association (OSAA), Oregon State EMS Committee, Oregon Chapter of the National Association of EMS Physicians (NAEMSP), West Region and Oregon Chapters of the National Association of State EMS Officials (NASEMSO) and the Rural EMS Initiative, among others. Continuing to build and strengthen these networks allows ORH to amplify the issues of Oregon’s rural and frontier EMS providers and identify a broader scope of resources to assist them.

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

ORH is working in collaboration with the Idaho Department of Health and the Washington Department of Health to leverage CAH specific pricing and programing with the University of Washington’s Tele-Antimicrobial Stewardship Program (UW-TASP) which offers weekly didactic/ECHO-based learning sessions on various subjects pertaining to antimicrobial stewardship programs (ASP) as well as numerous toolkits, resources, and expert technical assistance to assist CAHs in implementing and maintaining ASP programs within their facilities.

Please describe how your state Flex Program is reaching out to non-traditional partners to support its work.

ORH values its partnerships with both traditional and non-traditional partners to support their Flex work. Their Rural and Frontier Listening Tour, Annual Forum on Aging, and EMS activities provide the ideal opportunities to bring CAHs together with community resources that help them leverage and expand the assistance and expertise provided and also ensures that CAH challenges and priorities are widely understood and on partner agendas. Examples of these partnerships include Local Coordinated Care Organizations (CCOs), Local Public Health Authorities (LPHAs), Oregon Association of Hospitals and Health Systems, the Office of the Governor, State Representatives and Senators, Oregon Center for Nursing, Oregon State Nursing Board, Oregon Medical Board, Housing Authorities, community colleges, workforce collaboratives, gerontology associations, mental health service organizations, National Association of EMS Physicians (Oregon Chapter), Oregon EMS Association, Oregon State EMS Committee, EMS Supervising Physicians, and multiple offices within the Oregon Health Authority including: Health Policy and Analytics, Behavioral Health Policy, Primary Care, Health Information Technology, External Relations, the Director’s Office, Provider Services, Transformation Center, and EMS/Trauma Systems (OHA EMS/TS) Division, among others.

Program Statistics

Do you have any hospitals interested in converting to CAH status?:
Type of Organization University
Staffing (FTE) 3.95
Website Organization Website 
Number of CAHs 25

Flex Program Staff

Robert Duehmig
Interim SORH Director, Oregon
(503) 494-4450
Sarah Andersen
Director of Field Services, Oregon

Director of Field Services since September 2019.

Stacie Rothwell
Program Manager, Rural Health Outcomes, Oregon
(503) 494-7416

Specialty Areas / Background

Provides subject matter expertise, evidence-based support and technical assistance to rural Oregon hospitals, clinics and community stakeholders on quality improvement and improving health outcomes.

Program Manager since September 2015

Rondyann Gerst
Field Services Program Manager for Rural Health Clinics, Oregon

Rondyann is the Rural Health Clinic (RHC) Program Manager at the Oregon Office of Rural Health (ORH) and is ORH’s subject matter expert on RHCs. In her role, she provides technical assistance to RHCs in compliance activities, billing and coding, and operational improvements. She also assists private physician offices who desire to convert to RHC status.

Stepha Dragoon
Rural Population Health Program Manager, Oregon

Rural Population Health Program Manager since November 2021

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.