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Pennsylvania Office of Rural Health

Top Flex Activities

CAH Quality Improvement

All 16 critical access hospitals (CAHs) in Pennsylvania meet 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. Due to the dedication of CAH staff and ongoing technical assistance efforts by PORH’s QI Coordinator, there was significant EDTC performance improvement for Pennsylvania’s CAHs in FY20. Pennsylvania’s EDTC composite score increased by 11 points in FY20. Pennsylvania’s 2020 EDTC reporting rate of 100% was higher than the national reporting rate of 92.0%. Compared with all CAHs nationally, CAHs in Pennsylvania scored significantly better on 9 measures, significantly worse on 0 measures, and did not have significantly different performance on 0 measures.

Throughout FY20, the Pennsylvania Office of Rural Health’s (PORH) QI Coordinator continued to collect and submit Pennsylvania’s EDTC data utilizing Stratis Health’s collection tool. During the periods when MBQIP reporting was optional, PORH staff continued to encourage the submission of EDTC and all MBQIP data. Stratis Health continues to be a significant resource for PORH and the State’s CAHs for any questions or issues with the EDTC reporting process.

To optimize the treatment of infections and reduce adverse events associated with antibiotic use, all Pennsylvania CAHs participate in the Antibiotic Stewardship Program (ASP). All 16 CAHs have implemented programs and are meeting each of the seven program 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 programs include collaboration 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. 

PORH’s QI Coordinator continues to engage with CAHs on their ASP programs to assist with the improvement of the seven elements and to encourage collaboration and 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 develop protocols of recommended initial antibiotic treatment regimens for each. The protocols are provided to outpatient and specialty physicians and are built into their EHR software so that antibiotic choices are automatic. The EHR software also requires a diagnosis to order the correct antibiotic and requires a stop or renewal 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, are reviewed for appropriateness. This CAH is assisting another CAH in strengthening their antibiotic stewardship program.

To improve access to care, all Pennsylvania 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. CAH 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.

Pennsylvania’s CAHs are active participants in quarterly webinars and in-service programs provided by 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 QI Coordinator also meets with new QI Directors to educate them on MBQIP and QI resources and serves in a technical assistance capacity to new and existing QI staff.

CAH Operational and Financial Improvement

For the state’s CAHs, no other activity conducted 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 $33.4M. Since this program’s inception in 2008, Pennsylvania’s CAHs have received a total of $275M in reimbursements.

Due to pandemic-related under-expenditure of funds in travel and meeting budget categories, PORH’s Flex staff identified an opportunity to improve revenue cycle management and other operations within the hospitals and provider-based rural health clinics. 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 were presented every three weeks. All webinars were recorded, and the recording and slides were distributed to all CAHs and RHCs after the live event.

The Pennsylvania Flex Program has a long-standing collaboration with the Pennsylvania Trauma Systems Foundation (PTSF) to improve trauma services in rural areas of the state. PTSF is the accrediting body for trauma centers in Pennsylvania and was created by the combined efforts of the Pennsylvania Medical Society, the Hospital and Healthsystem Association of Pennsylvania, the Pennsylvania State Nurses Association, the Pennsylvania Emergency Health Services Council, and the Pennsylvania Department of Health.

Accredited trauma centers must be continuously prepared to treat the most serious life-threatening and disabling injuries. To receive trauma designation, each hospital participates in a thorough review process that includes an onsite assessment of the hospital’s resources and capabilities to care for patients with traumatic injuries. Pennsylvania trauma programs reach across emergency department staff, hospital, and local emergency medical services providers, and first responders across communities to provide 24/7 care.

Over the last five years, PORH has utilized Flex funding to assist four Pennsylvania CAHs with achieving Level IV trauma designation. The first Pennsylvania CAH achieved Level IV designation in 2016, followed two years later by a second CAH in 2018. PORH utilized FY20 Flex funding to support two additional CAH Level IV trauma designations and two re-certifications. CAHs that pursue Level IV designation must pass an accreditation survey to become certified and must receive an accreditation panel review every three years (at a minimum) to maintain their designation. Hospital staff must complete required trauma education and training and submit data to the PTSF trauma registry which collects data on seriously injured patients and provides analysis and reporting on all traumas in Pennsylvania.

CAH Population Health Improvement 


PORH has partnered with the Pennsylvania Department of Health and with the Pennsylvania Rural Health Redesign Center Authority to assist with the planning, development, and implementation of the Pennsylvania Rural Health Model (PA RHM). The PA RHM is the first alternative payment model in the country focused entirely on rural hospitals. The Model, which launched on January 1, 2019, 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 that hospitals receive a consistent monthly payment that is not tied to patient volume. During the first year, five rural hospitals (three CAHs), four commercial payers, and Medicare participated. There are currently 19 hospitals, including five CAHs, participating in Year 4 of the  Model.

PORH has utilized Flex funding to support CAH recruitment and transformation plan implementation for the PA RHM. As a requirement for participation in the PA RHM, each hospital must create a transformation plan specifying how they will move from volume to value focusing on the specific population health challenges in their communities. 

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 chronic 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 these patients in greatest need, both to achieve the best patient outcomes and to help the hospital succeed under the Model.

Participating hospitals identified Chronic Obstructive Pulmonary Disease (COPD) is a chronic care management opportunity and are working as a cohort to collaborate and develop best practices. For the FY19 and FY20 periods of performance, PORH utilized Flex funding to assist CAHs in prevention and management activities for COPD. In FY20, the PA RHM team and PORH worked with Quality Insights to upgrade the online COPD training platform developed for providers in FY19. The upgrade includes program templates and resources and allows all participating providers to utilize continuing education credits, including Continuing Medical Education (CME) credits and Continuing Education Units (CEU). The anticipated outcome of this training is to improve the knowledge of providers on successful practices for COPD prevention, and better care coordination and management of COPD patients to improve quality of life and patient outcomes. The course also offers resources and templates to assist hospitals in setting up or enhancing existing COPD chronic care management programs.

Due to the pandemic, work on this project was delayed and the FY19 COPD training platform was not released to the PA RHM team until October 2020. Based on the immediate feedback from providers requesting continuing education credits for this advanced training, PORH and Quality Insights partnered on an upgrade for the course in FY20. Providers are pleased with the ability to earn continuing education and with the expanded resources and templates that can be utilized to set up or enhance their COPD programs. All hospitals currently participating in the PA RHM have access to this course and all resources and templates. To date, only one hospital has implemented a COPD chronic care management program. PORH and the PA RHM team anticipate that additional hospitals will implement programs once the pandemic and staffing issues have improved. Additional Flex activities focused on CAH transformation goals continue to be developed with the PA RHM team.

Innovative Model Development 

The Practice Operations National Database (POND) from Lilypad is a web-based practice benchmarking application designed specifically for Rural Health Clinics (RHCs). 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. These data also give the SORH information from which tailored technical assistance can be planned.

In 2017, PORH subscribed to POND, making it available to all RHCs in Pennsylvania but had little success recruiting RHCs for participation. In 2018, PORH’s Rural Primary Care and Integration Coordinator became a Certified Rural Health Clinic Professional and provided support to RHCs in three different health systems on billing, coding, administration, and the use of POND. At that time, the State had 70 RHCs, and only two were enrolled in POND.

In 2019, PORH planned to recruit an additional eight RHCs for a total of 10 enrolled and actively participating in POND by the end of FY19. PORH engaged with Lilypad and the National Organization of State Offices of Rural Health (NOSORH) on their Tailored Technical Assistance Program to assist with providing customized financial and operational technical assistance for Pennsylvania’s RHCs. PORH assisted one RHC with compilation of their cost report and trained new finance staff. PORH also assisted another RHC with MCO enrollment for a dental provider. The Rural Primary Care and Integration Coordinator partnered with The Compliance Team to learn more about RHC Surveys and to learn how to assist RHCs by conducting mock surveys. Unfortunately, just as the Rural Primary Care and Integration Coordinator acquired this knowledge, COVID-19 prevented travel across the State.

In November 2019, PORH hosted the first Rural Health Care Transformation Summit, which was attended by small rural hospital and RHC leadership, to focus on the transition from volume to value. This first summit was very successful and was attended by 20 RHC leaders. The RHC afternoon breakout session was tailored to RHC relevant topics, including a National RHC update presented by the National Association of Rural Health Clinics (NARHC) and a presentation on POND. Positive feedback was received by participants and the Rural Primary Care and Integration Coordinator was able to build a more robust RHC email distribution list. This distribution list proved to be invaluable and was used by the Rural Primary Care and Integration Coordinator to communicate regular updates regarding COVID and other important rural-relevant information on a regular basis. Participant feedback from the summit also recommended the addition of RHC leadership at all PORH quarterly meetings which was implemented for all future meetings.

PORH included RHC leadership in every quarterly Pennsylvania CAH Consortium meeting for FY19 which included morning plenary sessions for all health care leaders and separate afternoon breakout sessions for RHC leadership, QI Directors, and hospital leadership. PORH’s 2020 Rural Health Care Transformation summit was held virtually in October 2020 and was even more successful with 26 RHC leaders attending. Due to significant health care staffing shortages and high COVID admissions in October 2021, PORH staff postponed the Rural Health Care Transformation Summit until February 2022 when better CAH/RHC leadership attendance is possible. 

For the remainder of FY20, PORH’s quarterly CAH/RHC meetings had strong attendance from RHC leadership. Feedback from these meetings indicated a need for additional financial and operational training for CAHs and RHCs so PORH engaged Stroudwater Associates, to present seven, virtual, one-hour, financial and operational webinars to CAH and RHC leadership on topics including:

  • CAH/RHC 101;
  • Managerial Accounting;
  • Leveraging RHCs to Expand Behavioral Health Services;
  • HIPAA Compliance;
  • Provider Contracts
  • The Use of Market Analytics to Drive Decision-Making; and
  • Affiliation Value Curve.

PORH also offered scholarships during the spring of 2021 for two new RHC leaders to attend NARHC’s fall Certified Rural Health Clinic Professional course. Both leaders completed coursework on RHCs, designed to educate participants on all aspects of operating a successful RHC. Both scholarship awardees successfully completed the course and PORH is planning to offer two more scholarships for the Spring 2022 session so that additional leaders can be educated.

The impact of these additional resources and events for Pennsylvania’s RHCs has resulted in a significant increase in requests for technical assistance and RHC attendance to PORH events and meetings. PORH has assisted with RHC billing, coding, financial analysis, cost reporting, facility requirements, medical-dental integration, and behavioral health integration. This increase in technical assistance and communication by PORH’s Rural Primary Care and Integration Coordinator resulted in the successful recruitment of six provider-based RHCs from four CAHs to participate in Pennsylvania’s FY21 Year 3 Flex RHC QI Project. This project also will increase the number of RHCs enrolled in POND for FY21.

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

PORH continues to work with the 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.

The pandemic has significantly increased the number of rural hospitals 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, ongoing 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?:
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 

Sandee Kyler
Flex Coordinator, Pennsylvania

Flex Coordinator since May 2022

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.