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Pennsylvania Office of Rural Health

Top Flex Activities

Program Area: Support for Quality Improvement

The critical access hospitals (CAHs) in Pennsylvania continue to complete the National Healthcare Safety Network’s (NHSN) “Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel” with a deadline of May 15, 2019. To better assist the CAHs in reaching 100% participation, the Pennsylvania Office of Rural Health (PORH) collaborates with the Nursing Services Consultant in the Division of Immunizations, Pennsylvania Department of Health. To increase the immunization coverage levels in Pennsylvania, the consultant has provided a series of patient education videos designed to dispel the myths surrounding immunization. These videos are free to download and use in waiting or exam rooms. This information also was downloaded onto PORH’s quality improvement (QI) website.

To improve Hospital Acquired Infections (HAI) measures, all CAHs continue to be active participants in the Quality Net Program through CMS and in all Medicare Beneficiary Quality Improvement Project (MBQIP), Hospital and Comsumer Assessment of Healthcare Providers and Systems (HCAHPS), and Emergency Department Transfer Communications (EDTC) programs. 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 the Hospital and Healthsystem Association of Pennsylvania (HAP) for the Sepsis and Antimicrobial Stewardship programs. PORH continues to work closely with quality and infection control experts from HAP. 

PORH’s QI Director developed a QI resources library on the PORH website for the CAH QI Directors to increase access to a wide range of QI resources. Quarterly QI conference calls are held with the QI Directors and quarterly face-to-face meetings are held in the intervening months. 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 meets with new QI Directors to educate them on the QI process.

Program Area: Support for Financial and Operational Improvement

PORH provides the state’s CAHs with a wide range of resources, including the development of ideas for continued hospital viability, vendor information on restructuring hospital billing and coding departments, and reviewing and maximizing contractual agreements with insurance companies and third-party payers. 

Pennsylvania CAHs continue to benchmark their financial and quality metrics against other CAHs in the state and across the nation and against prospective payment system (PPS) hospitals using the Hospital Strength Index. The index, market, value, and finance percentile ranks are compared against peer hospitals and previous year performance. 

The Pennsylvania Flex Program supports the consultant service to the state’s CAHs to collect and analyze their Medicaid cost reports prior to submission to the State Medicaid agency to facilitate the supplemental Medicaid payments to each CAH, based upon 101% reimbursement. The average supplemental payment per hospital is over $1.75M. 

An operational area for improvement in this current program year is to improve the operations of the CAHs' affiliated primary care practices. Quarterly meetings of the Pennsylvania Critical Access Hospital Consortium during the last year focused on value-based payment strategies for primary care. The September 2018 quarterly consortium meeting included presentations by the Pennsylvania Department of Health on the Pennsylvania Rural Health Transformation Model. The final list of participating hospitals has not been released but it is anticipated that three to four CAHs will be participating in the model, set to launch on January 1, 2019. The model will provide stable financing for participating hospitals and incentivize the hospitals to address population health and health status indicators in their service delivery areas.

The “Cost Master” project was implemented in 2016 with four hospitals participating initially.  Two additional CAHs have been added. PORH is partnering with Stroudwater Associates to assist the CAHs in identifying the true costs of providing each service listed on the hospital’s Chargemaster. Each hospital’s cost report also is being analyzed to determine the cost by service line of selected services. PORH is working to add several additional CAHs to the Cost Master project and is partnering with the Pennsylvania Department of Health to add hospitals that will be participating in the Pennsylvania Rural Health Transformation Model.

The majority of Pennsylvania’s CAHs continue to participate in the 340B program. This critical program not only improves each hospital’s financial viability but also provides lifesaving prescriptions at significantly discounted rates to patients who could not afford them otherwise.

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

As noted, three to four CAHs are anticipated to participate in the Pennsylvania Rural Health Transformation Model, effective January 1, 2019. The model will provide stable financing for participating hospitals and incentivize the hospitals to address population health and health status indicators in their service delivery areas.

PORH recognizes the need for successful community paramedicine programs in Pennsylvania. PORH is partnering with the Pennsylvania Emergency Health Services Council’s Pennsylvania EMS for Children Project Manager to address of the emergency medical needs of rural children and attended the 2018 Community Paramedicine Health Summit on October 17, 2018. PORH staff also participate in the Pennsylvania Department of Health Statewide Emergency Services Advisory Council to remain current on State EMS issues and to represent the interests of rural EMS providers.

PORH partners with the Pennsylvania Trauma Systems Foundation (PTSF) to improve trauma services in rural areas in the State. Three CAHs have been pursuing Level IV Trauma designation with one of these CAHs being designated in November 2016 and another scheduled for November 2018. Two additional CAHs have expressed interest in beginning the process. Two other rural hospitals have previously been designated at Level IV trauma centers. 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. 

Through the Flex Emergency Medical Services Sustainability Project, PORH will improve care for the non-emergent patient, reduce the total cost of care for frequent EMS users, and improve access to continuing education for EMS personnel. The project also will improve the sustainability of rural EMS agencies and improve coordination and integration between the Pennsylvania Rural Health Transformation Model pilot hospitals and regional systems and partners of care. PORH will complement and support the Pennsylvania Rural Health Transformation Model and its participating rural hospitals by developing partnerships with local EMS providers, other state EMS resources, such as the Pennsylvania Department of Health’s Bureau of Emergency Medical Services and the Pennsylvania Emergency Health Services Council, to develop a Community Paramedicine Program that will support and align with the Pennsylvania Rural Health Transformation Model.

PORH and the Pennsylvania Department of Health’s Bureau of Emergency Medical Services submitted a proposal to the National Organization of State Offices of Rural Health (NOSORH) to host the Joint Committee for Rural Emergency Care (JCREC) annual conference in Pennsylvania in one of the upcoming years.  

Please provide information about Collaboration/Shared Services 

Population Health and Health Care Transformation PORH is one of the primary stakeholders participating with the Pennsylvania Department of Health’s State Health Innovation Plan (HIP). PORH staff members serve on the Population Health Workgroup and also co-chair the Health Information Technology Advisory Committee. PORH collaborates with the State’s Health Promotion Council (HPC) to equip the State’s CAHs with the resources and tools needed to improve and maximize optimal patient outcomes, specifically, chronic disease prevention programs. The HPC, with funding from the Pennsylvania Department of Health and the Centers for Disease Control and Prevention (CDC), has created the Pennsylvania Community-Clinical Integration Initiative (PA CCI). PA CCI is a statewide project to improve capacity-building and infrastructure to support those with, or at risk for, diabetes and its related chronic diseases and risk factors. PA CCI is working across the state to bring partners together to address the key issues that create barriers to access and utilization of evidence-based Diabetes Prevention (DPP) and Diabetes Self-Management Education (DSME) programs. These challenges include issues related to patients, primary care providers, health care communication technology, delivery systems, and health insurers/payers. PA CCI consists of multiple components in various health care sectors to accomplish its work. HPC continues to assist the CAHs in developing the program in their hospitals. Several of the CAHs have implemented employee wellness programs, community programs, and the DPP and DSME programs. A cohort of CAHs is working with the Healthy Communities Institute (HCI) to access population health data, best practices and to utilize the platform’s Community Health Needs Assessment (CHNA) tool for their hospitals and communities. HCI, in addition to displaying health data, also provides a comprehensive list of best practices to improve the health of the community. Two initiatives in the State that met with great success and can be considered to be “promising practices” are highlighted below. One initiative is the Opioid and Narcotic Challenge, which focuses on the following:

  • continuing collaboration with Clinical Recovery and Addiction Specialists and the Armstrong Indiana Clarion Drug & Alcohol Commission (ARMOT) to facilitate substance abuse disorder treatment programs in other counties;
  • assisting CAHs in developing innovative policies and procedures to decrease opioid prescribing;
  • disseminating a Guideline for Chronic Pain Management in the emergency department;
  • collaborating with other health care entities and scholars to develop innovative ways to combat this issue;
  • working with area community-based clinics and other health care providers to determine the most effective method to assist patients who are addicted; 
  • and tracking all narcotic prescriptions that are prescribed in the hospital.

Another promising practice focuses on improving obstetric care in the emergency department with an emphasis on the following:

  • collaborating with certified nurse midwives to develop an innovative program that specifically addresses concerns and challenges in maternal health in rural Pennsylvania;
  • assisting CAHs in developing policies and procedures to facilitate optimal outcomes for mothers and newborns;
  • and continuing efforts with EMS and Life Flight services on obstetric competencies for all emergency department staff with a continued commitment to be adequately prepared for obstetric emergencies.

Program Area: Support for Integration of Innovative Health Care Models

As indicated above, several CAHs and other rural hospitals are participating in the Pennsylvania Rural Health Transformation Model. PORH has committed resources to population health and can serve as a resource to the other member organizations. More complex data analysis and visualization will be explored. Development of a comprehensive approach for small health systems to develop targeted interventions on identified population health issues will be needed. With the pending implementation of the Pennsylvania Rural Health Transformation Model, Pennsylvania will be focusing on alternate payment models (global budgeting) for rural hospitals. The new Payment Model focal area will be an important activity area, as will other Flex-related areas such as Operations and Care Coordination.

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

Partner organizations include the Health Promotion Council, the Pennsylvania Patient Safety Authority, the Pennsylvania Department of Health, and the Hospital and Healthsystem Association of Pennsylvania to provide support and technical assistance on the transition to value-based care. It is the shared goal of collaboration to provide all CAHs with the tools required to provide safe and superior delivery of patient care.

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

PORH continues to work with Pennsylvania CAHs 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 our quarterly CAH hospital meetings in State College.  

As noted previously, a cohort of CAHs is working with the Healthy Communities Institute (HCI) to access population health data, best practices and to utilize the platform’s Community Health Needs Assessment (CHNA) tool for their hospitals and communities. This activity will be on-going in fiscal year (FY) 2019. The CAHs continue to meet with their community health partners to develop their CHNAs, select priority measures for improvement, identify improvement projects and measure performance outcomes from the selected measures. The HCI interactive website permits the CAHs to view county data for nearly 100 measures of health and sociodemographic data and permits comparisons with national standards such as Healthy People 2020. From the PORH website, the CAHs can easily access the data. Health disparity data, Healthy People 2020 data, best practices, and socioeconomic data also are available on the PORH website and the CAHs’ websites. Pennsylvania currently has data for eight counties in Pennsylvania. A total of 20-30 counties are planned to be integrated into the project in the upcoming and subsequent years.

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

The Pennsylvania Flex Program and nine of the CAHs are participating in a swing bed research project led by the University of Minnesota and Stroudwater Associates. The CAHs began collecting measures in April 2018 and the project will be completed by August 2019. 

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

The Pennsylvania Flex Program continues to conduct annual assessments of the state’s CAHs using data and reports from the Flex Monitoring Team (FMT) and the Pennsylvania Health Care Cost Containment Council (PHC4). PORH compiles data from these sources and disseminates the data to each CAH annually at a Pennsylvania Critical Access Hospital Consortium quarterly meeting.

The state’s CAHs continue to benchmark their financial and quality metrics against other CAHs in the state and nationally and against PPS hospitals using the Hospital Strength Index. The index, market, value and finance percentile ranks are compared against peer hospitals and previous year performance.

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

Yes

Program Statistics

Type of Organization University
Staffing 2.0 FTEs
Number of CAHs 15
Website URL Organization Website

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 Johnston
Quality Improvement Coordinator, Pennsylvania
(814) 863-8214

Quality Improvement Coordinator since September 2016

Derek Hartman
Graduate Student Intern, Pennsylvania
(814) 863-8214
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, $1,100,000 (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.