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Pennsylvania Office of Rural Health

Top Flex Activities

CAH Quality Improvement

All 16 critical access hospitals (CAHs) in Pennsylvania meet Medicare Beneficiary Quality Improvement Project (MBQIP) participation requirements and report required MBQIP core quality measures including Hospital and Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and Emergency Department Transfer Communications (EDTC) programs, as well as other inpatient and outpatient metrics.

One of the highlights of Pennsylvania’s MBQIP is the EDTC program. Pennsylvania’s CAHs scored significantly higher than the national average on all EDTC domain metrics. To achieve this quality milestone, one of Pennsylvania’s CAHs developed a robust Emergency Department Performance Improvement Model. The model was developed to provide physician-specific quality metric results in a transparent format to improve previously-low EDTC metrics. These results are shared each month with all providers, the Vice President of Operations, the Director of Nursing, and the physician contracting company. Metrics include Door to Provider Time, Room to Provider Time, Overall Time in Emergency Department for Treated and Released Patients, and Overall Time in the ED for Admitted Patients. The model also evaluates doctor/provider satisfaction to include Provider Courtesy, Provider Took Time to Listen, Provider Was Informative Regarding Treatment Options, and Provider Illustrated Concern for Comfort. After one year of model implementation, the hospital consistently scored high on all EDTC metrics. To assist other CAHs receiving low EDTC scores, the hospital presented their model at a quarterly CAH meeting and continues to serve as a mentor to other hospitals. 

To optimize the treatment of infections and reduce adverse events associated with antibiotic use, all CAHs participate in the Antibiotic Stewardship Program (ASP). All 16 CAHs have implemented programs and are meeting all seven elements. Many of the CAHs are collaborating with the Hospital Improvement Innovation Network (HIIN) and the Hospital and Healthsystem Association of Pennsylvania (HAP) on the reduction of patient harm programs.  Other CAHs have implemented customized, robust ASPs designed to focus on their relevant needs. All CAH programs collaborate with clinicians, pharmacists, infectious disease experts, laboratory directors, chief nursing directors, and medical directors to implement evidence-based protocols to reduce infection, adverse event rates, and antibiotic resistance. The SORH’s QI Coordinator continues to engage with all CAHs on their ASP programs to assist with improvement of all seven elements and to encourage collaboration and the sharing of best practices.  One CAH presented their ASP best practices during a quarterly QI meeting.  This CAH has a certified infection control specialist leading their ASP who developed an innovative biogram that illustrates antibiotics utilized for specific organisms, type of organism, relative treatment costs per day, and protocol development.  They utilize telemedicine to consult with an infectious disease specialist and ASP pharmacist to determine the type of infectious diagnoses for inpatient and ED treatments, and developed protocols of recommended initial antibiotic treatment regimens for each.  The protocols are provided to all CAH outpatient and specialty physicians and are built into the EHR so that the antibiotic choices are automatic.  They also require a diagnosis to order the correct antibiotic and require a stop/renew order at 48-72 hours. Pharmacy interventions are tracked for changes to renal dosing for the antibiotics and changes based on laboratory cultures, patient outcomes, and de-escalation, and review the antibiotic orders for appropriateness. This CAH is assisting another CAH in strengthening their program.

To improve access to care, all CAHs have implemented telehealth programs. The goals of each telehealth program include improving patient outcomes, increasing access to specialists, providing 24/7 access to specialists, improving leverage of limited physician resources, reducing hospital readmissions, improving patient engagement and satisfaction, reducing cost of care delivery, and improving patient convenience. Telehealth programs that have been implemented include obstetrics, pediatrics, burns, wound care, neurology, psychiatry, infectious disease, stroke assessment, cardiac care, pharmacy, allergy/immunology, and wellness/medication checks. Recently, the SORH’s QI coordinator successfully completed “Telehealth 101” offered through the Northwest Regional Telehealth Resource Center.

Pennsylvania’s CAHs are active participants in quarterly webinars and in-service programs provided by the Pennsylvania Office of Rural Health (PORH) and HAP.  To facilitate successful quality improvement programs, PORH’s QI Coordinator serves as a mentor for the state’s CAHs and offers additional training upon request, specific to each CAH’s needs.

PORH’s QI Coordinator continues to update the QI Resource Library on the PORH website to increase access to a wide range of QI resources for rural hospitals. QI conference calls or face-to-face meetings with the CAH QI Directors are held either independently or in conjunction with the CAH Consortium meetings.  These events facilitate discussion on QI initiatives and shared learning.  A QI Resource Manual has been developed which is embedded on the QI section of PORH’s website.  The SORH’s QI Coordinator also meets with new QI Directors to educate them on MBQIP and QI resources and serves in a technical assistance (TA) capacity to new and existing QI staff.

CAH Operational and Financial Improvement

For the state’s CAHs, no other activity conducted by PORH and the Pennsylvania Flex Program is as significant to the CAHs as the effort focused on the Medicaid supplemental funds provided by the Commonwealth of Pennsylvania and CMS. PORH contracts with a retired CAH CEO to calculate the shortfall amount for Medicaid services provided by the CAHs using the Medicaid Cost Report. This calculation is provided to the Pennsylvania Department of Human Services (DHS), the state’s Medicaid Agency, which audits the report. After the total is validated, the Commonwealth budgets for the shortfall and the CAHs are reimbursed 101 percent of their Medicaid costs in April of the following year. Last year’s payments to CAHs were in excess of $31M. Since this program’s inception in 2008, Pennsylvania’s CAHs have received a total of $242M which is an average of just under $2M per CAH annually.

Due to pandemic-related under-expenditure of funds in travel and meeting budget categories, PORH’s Flex staff identified an opportunity to improve CAH revenue cycle management functions by offering coding and billing training. This training was conducted at the end of April 2020 during the time that the state had an order in place to restrict non-essential and elective services due to the pandemic. Because of these restrictions, health care facilities faced significant financial deficits and needed to ensure that they were coding and billing correctly to prevent additional revenue losses. Since facility staff had reduced workload during this time, PORH anticipated a strong attendance for virtual courses. Coders, billers, providers, and management gained a clear understanding of changes related to telehealth and other federal waivers to ensure they correctly implemented the changes to federal, state, and commercial insurers. PORH contracted with ArchProCoding to conduct two virtual coding and billing courses: a rural hospital-focused boot camp, and a rural health clinic (RHC)-focused boot camp. PORH had a strong turnout for both two-day courses with 85 attending the hospital-focused event and 54 attending the RHC-focused boot camp. Graduates received 11 CEUs for completion of each course and were eligible to take a certification exam.

Due to the continued focus on revenue cycle management and CAH and RHC survey requests for additional education in other financial topics, PORH engaged Stroudwater Associates to develop a series of ten webinars with topics including CAH/RHC 101, the Use of Market Analytics to Drive Decision-Making, Revenue Cycle Best Practices, Leveraging RHCs to Expand Behavioral Health Services, and many others. These webinars began in March 2021 and will be presented every three weeks. All webinars are recorded, and the recording and slides are distributed to all CAHs and RHCs after the live event.

Over the past two years, PORH has made significant progress working with the State’s 66 RHCs. In response to RHC requests for additional TA and education, PORH modified the quarterly CAH meeting structure to regularly include RHC leadership. Each meeting now includes a morning session for all attendees and utilizes the afternoons for three separate educational breakout sessions for CAH leadership, QI Directors, and RHC leadership. To assist RHCs with utilizing Lilypad®’s Practice Operations National Database (POND) and other customized state reporting to identify areas of improvement. This additional activity provides technical assistance for PORH to review RHCs processes, cost reports, etc. and recommend changes and best practices to improve RHC operations.

One of the longest-standing partnerships and one that is of greatest benefit to the state’s CAHs has been a partnership with the Penn State College of Engineering and its “Learning Factory.” As a capstone project for senior industrial engineering students, the hospitals receive assistance from a team to improve a process or increase efficiency in a specific department.  Annually, the CAHs submit proposals to the Learning Factory.  If accepted, the lead faculty member assigns a team that gains access to the facility and collects project-related data.  At the conclusion of the project, the team makes a presentation at the hospital, a quarterly Pennsylvania CAH Consortium meeting, and at the Learning Factory Showcase.

CAH Population Health Improvement 

With rural hospitals in Pennsylvania in financial distress, Pennsylvania continues to identify innovative strategies to assist rural hospitals and keep them open.  The Pennsylvania Rural Health Model (PA RHM) is the first alternative payment model in the country focused entirely on rural hospitals and is funded by the Center for Medicare and Medicaid Innovation (CMMI).  The model, which launched on January 1, 2019 with five participating rural hospitals (three CAHs), four commercial payers, and Medicare, seeks to address the financial challenges faced by rural hospitals by transitioning them from fee-for-service to global budget payments. The model aligns incentives for providers delivering value-based care and smooths cash flow so the hospitals receive a consistent monthly payment that is not tied to volume.  PORH has supported the model since its inception and continues to provide Flex funding for CAHs participating in or considering participation in the Model.

As a requirement for participation in the model, each participating hospital must create a transformation plan describing their transition from a volume- to value-focus. In order for hospitals to succeed financially under the model, they must reduce Potentially Avoidable Utilization (PAU), which is driven by readmissions and inappropriate use of the emergency department. In many of the hospital transformation plans, a need for care management to address high-cost, high-need (HCHN) patients was identified. This presented an opportunity for the hospitals to collaborate and think strategically about assisting patients in greatest need, both to achieve best patient outcomes and to ensure success under the Model.  Participating CAHs identified Chronic Obstructive Pulmonary Disease (COPD) as a chronic care management opportunity and Flex funding has been utilized to create a COPD-focused clinician training platform for participating hospitals.

Additional Flex activities focused on CAH transformation goals are being developed with the PA RHM team. There are currently 18 hospitals, including five CAHs, participating in the Model which is currently in Year 3. Due to the pandemic and changes in recruitment efforts, CMMI has authorized a fourth year for recruitment. Hospitals recruited this year will begin participation in the Model in 2022. A total of thirty hospitals is required to participate by the end of this final recruitment year.

PORH collaborates with the Pennsylvania Trauma Systems Foundation (PTSF) to improve trauma services in rural areas.  Two Pennsylvania CAHs have been designated Level IV trauma centers and two additional CAHs are pursuing designation in 2021. Efforts are ongoing to have these CAHs designated as Level IV Trauma Centers and to identify other CAHs for participation. Trauma patients, prior to being transferred to a Level I or II trauma hospital, will receive optimum care as evidenced by trauma registry statistics.

Innovative Model Development 

As noted, Pennsylvania has prioritized the implementation of the PA RHM as an innovative solution to stabilize the financial viability of rural hospitals and improve rural community health in the state. Rural hospitals are the lifeline of these communities, providing affordable, accessible health care and economic vitality. PORH has partnered with the Pennsylvania Department of Health (PA DOH) since 2017 to assist in the development and implementation of the model. In FY 18 and FY19, PORH served as the lead organization through a contract from the PA DOH to assist the state in the first phase of implementing the model, which provided financial and operational assessment, hospital recruitment, development of the State’s Center for Rural Health Redesign, and support for COPD initiatives. PORH will continue to utilize Flex funding to support hospital recruiting and transformation goal implementation for participating CAHs.

In response to the national Flex program’s efforts to address rural disparities in Chronic Obstructive Pulmonary Disease (COPD) services, CAHs across the nation identified COPD services and resources as a need. The SORH’s QI coordinator joined other national Flex Coordinators and experts to develop the COPD Manual, A Rural Hospital Guide to Improving Chronic Obstructive Pulmonary Disease (2019).  This manual serves as a resource that stresses the importance of COPD treatment and increases awareness about the potential community and patient benefits of implementing pulmonary rehabilitation services to support patients with COPD. Flex funding has been utilized to share the COPD manual throughout the state and to create a COPD-focused clinician training platform for participating PA RHM hospitals.

With the state’s focus on transitioning from volume to value, PORH has placed a greater emphasis in assisting CAHs with provider-based RHCs. In 2017, PORH had increased success working with many RHCs in the state. In 2018, PORH’s Dental Delivery Systems Coordinator became a Certified Rural Health Clinic Professional and provides support to RHCs on billing and coding, administration, and the use of the benchmarking application, POND.

POND is a web-based practice benchmarking application designed specifically for RHCs.  In 2017, PORH subscribed to POND, making it available to all RHCs in Pennsylvania.  POND provides a platform for RHCs to share blinded financial, operational, productivity, and compensation data. Once an RHC enters their practice data into POND, they have access to blinded benchmark data which can be utilized to guide practice improvements. POND also allows the Dental Delivery Systems Coordinator to maintain a current list of contacts for each RHC.

Currently, there are 66 RHCs in Pennsylvania, and PORH continues to enroll new RHCs in POND each month. Significant progress has been made in the last two years to increase RHC participation in meetings, education, and TA but it has been more challenging to get consistent data submissions from participating RHCs. PORH has provided more Flex funding to increase internal staff member’s RHC expertise and plans to continue to expand RHC educational opportunities to assist with participation in POND.

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

PORH continues to work with state’s CAHs and RHCs to encourage and expand networking activities.  PORH is a conduit for information sharing between hospitals and provides opportunities for CAH and RHC leadership to interact with their peers at regular CAH/RHC meetings virtually or in person.

With 18 hospitals (5 CAHs) participating the model and an additional year of recruiting in 2021, cohort opportunities between participating hospitals will continue to expand. Cohort development and sharing of best practices is required in the model.

The pandemic has significantly increased the number of rural hospital and RHC TA encounters PORH staff supported for 2020/2021. TA has been provided through daily and weekly informational e-mails, calls to facilities to ensure mandatory reporting requirements are met, educational offerings, on-going support for questions, and requests for staff collaboration on issues.

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

PORH has been a strong partner in the state’s implementation of the Pennsylvania Rural Health Model and assists other SORHs interested in the model in partnering with the state’s PA RHM experts.

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

PORH developed a strong partnership with the Pennsylvania Emergency Health Services Council (PEHSC) during the implementation of a Fiscal Year (FY) 2018 Flex Supplemental Project.  This project assessed Emergency Services in seven service delivery areas in northeastern Pennsylvania.  PORH continues this partnership with PEHSC and plans to expand Flex EMS activities in future years.

Program Statistics

Do you have any hospitals interested in converting to CAH status?:
Yes
Type of Organization University
Staffing (FTE) 2
Website Organization Website 
Number of CAHs 16

Flex Program Staff

Lisa Davis
State Office Director, Pennsylvania
(814) 863-8214

Specialty Areas / Background

  • Public health and policy
  • Special populations

State Office Director since June 1999 

Jennifer Edwards
Flex Coordinator, Pennsylvania
(814) 863-8214

Flex Coordinator since August 2018

Lannette Fetzer
Quality Improvement Coordinator, Pennsylvania
(814) 863-8214

Quality Improvement Coordinator since September 2016

Kelly Braun
Dental Delivery Systems Coordinator, Pennsylvania
(814) 865-9888

Dental Delivery Systems Coordinator since April 2016

Laura Zimmerman
Budget Assistant, Pennsylvania
(814) 863-8214

Budget Assistant since May 2015

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.