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Pennsylvania Office of Rural Health

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CAH Quality Improvement

All critical access hospitals (CAHs) in the Commonwealth 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.

The CAHs in Pennsylvania continue to complete the National Healthcare Safety Network’s (NHSN) “Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel." To better assist the CAHs in reaching 100% participation, the Pennsylvania Office of Rural Health (PORH) continues collaboration with the nursing services consultant in the Division of Immunizations, Pennsylvania Department of Health (PA DOH), and the Hospital and Healthsystem Association of Pennsylvania (HAP). To increase the overall immunization coverage levels in Pennsylvania, the consultant has provided a series of free patient education videos designed to dispel the myths surrounding immunization and can be utilized by the hospitals in waiting rooms. 

To improve Hospital Acquired Infections (HAI) measures, all CAHs continue to be active participants in the Quality Net Program through the Centers for Medicare & Medicaid Services (CMS). The three specific HAIs relevant to the state’s CAHs include clostridium difficile infection (C-Diff), methicillin-resistant staphylococcus aureus (MRSA), and catheter-associated urinary tract infections (CAUTI). In addition, the state’s CAHs are active participants in the informational webinars and in-service programs provided by HAP for the Sepsis and Antimicrobial Stewardship programs. PORH continues to work closely with quality and infection control experts from HAP. All Pennsylvania CAHs are meeting all seven elements of the Antibiotic Stewardship Program. To help facilitate the success of the Antibiotic Stewardship Program, PORH consulted with the Infection Prevention Specialist at one of the CAHs. She provided an in-depth webinar to all the Pennsylvania CAH Quality Improvement (QI) Directors and also offered additional training upon request. In addition, the PORH QI Coordinator provides additional resources that are specific to CAH needs.    

For the current period of performance, three Pennsylvania’s CAHs are continuing to participate in the Swing bed project with Stroudwater Associates and University of Minnesota. The goal of the project was to determine a set of quality of care metrics for Swing Bed patients and to continue collecting these measures for performance and quality improvement.  

PORH’s QI Director continues to add to the PORH QI resource library on the PORH website for hospitals to increase access to a wide range of QI resources. QI conference calls or face to face meetings in conjunction with the CAH Consortium meetings are held quarterly with the CAH QI Directors. These calls and meetings facilitate discussion on QI initiatives and shared learning.  A QI Resource Manual has been developed which is embedded on the QI website. PORH’s QI Coordinator also meets with new QI Directors to educate them on MBQIP and the quality improvement (QI) resources.

CAH Operational and Financial Improvement

With more than two thirds of 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 is the first alternative payment model in the country focused entirely on rural hospitals.  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. Doing so aligns incentives for providers to deliver value-based care and smooths cash flow so they 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 through activities for CAHs participating in or considering participation in the Model. 

The Cost Master data model was developed to monitor financial performance during a fiscal year by creating reporting tools that allow CAHs to set different payment methodologies (e.g., cost-based or fee-for-service) for different payer classes (e.g., Commercial, Medicare, Medicare Advantage, Medicaid, etc.). The Cost Master tool also serves as an advanced interim cost report tool which is a best practice for CAHs that need to closely monitor reimbursement from CMS. The Cost Master provides a foundation for detailed financial analysis to support operational improvement. The Cost Master project was initiated in 2016 with four participating hospitals. Four additional CAHs have been added in 2018.

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. 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), and 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 $28 million. Since this program’s inception in 2008, Pennsylvania CAHs have received a total of $158 million. 

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 of students 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. Upon 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 

In preparation for the launch of the Pennsylvania Rural Health Model, each participating hospital created a transformation plan describing how they will 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 Year 1 hospital transformation plans, a need for care management to effectively address high-cost, high-need (HCHN) patients was identified. This presented an opportunity for the hospitals to collaborate and think strategically about how to assist patients in greatest need, both to achieve best patient outcomes and to help the hospital succeed under the Model. Year 1 hospitals have identified Chronic Obstructive Pulmonary Disease (COPD) as a chronic care management opportunity and have agreed to work as a cohort to collaborate and develop best practices. 

After Year 2 hospitals are identified, transformation plans will be analyzed to determine if other Flex funded projects can be identified to support other care coordination efforts and population health initiatives.

PORH partners with the Pennsylvania Trauma Systems Foundation (PTSF) to improve trauma services in rural areas in the state. Two Pennsylvania CAHs have been designated Level IV trauma centers and an additional CAH will pursue designation in 2020. Efforts will be on-going to have these CAHs designated and to identify other interested CAHs. 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 mentioned previously, Pennsylvania has prioritized the implementation of the Pennsylvania Rural Health Model as an innovative solution to stabilize the finances 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 PA DOH since 2017 to assist in the success of the Model. PORH is the lead organization on a contract from the PA DOH to Pennsylvania State University to assist the state in the first phase of implementing the Model, which will provide financial and operational assessment, hospital recruitment, development of the State Center for Rural Health Redesign, and support for COPD initiatives. PORH will continue to support the implementation of the Model for participating CAHs with Flex funding throughout the upcoming period of performance.

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

The Practice Operations National Database (POND) from Lilypad 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 an avenue 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.

Currently, there are 70 RHCs in Pennsylvania, and only two are enrolled in POND. As this is a new program, PORH’s goal is to have at least 10 RHCs enrolled and actively participating in POND by the mid-2020. PORH plans to continue to add additional clinics in each year to build and expand the program. In addition to POND funding, PORH has added Flex funding support by means of targeted health system-specific webinars to assist in RHC recruitment.

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

PORH continues to work with Pennsylvania CAHs and RHCs to encourage and expand networking activities. PORH is regularly a conduit for information sharing between hospitals and provides opportunities for CAH leadership to interact with their peers at their quarterly CAH hospital meetings in State College.  

With additional hospitals joining the Model in Years 2 and 3, cohort opportunities between participating hospitals will continue to expand. Cohort development and sharing of best practices is required in the Model.

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

The Pennsylvania Flex Program and three Pennsylvania CAHs continue to participate in a swing bed project led by the University of Minnesota and Stroudwater Associates. The project was completed in August 2019 but data collection is still continuing. 

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

PORH has developed a strong relationship with the Pennsylvania Emergency Health Services Council (PEHSC) when working on the Fiscal Year (FY) 18 Flex Supplemental Project. This project was an assessment of Emergency Services in seven service delivery areas in northeastern Pennsylvania. PORH hopes to continue their partnership with PEHSC and expand Flex EMS activities in future years.

Program Statistics

Do you have any hospitals interested in converting to CAH status?:
Type of Organization University
Staffing (FTE) 2
Website Organization Website 
Number of CAHs 15

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

Laura Zimmerman
Budget Assistant, Pennsylvania

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, $1,009,121 (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.