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Pennsylvania State University

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Program Area: Support for Quality Improvement

The Pennsylvania critical access hospitals (CAHs) continue to complete the National Healthcare Safety Network’s (NHSN) “Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel” by May 15, 2018. To assist with reaching 100% CAH participation, the Pennsylvania Office of Rural Health (PORH) is collaborating with the Nursing Services Consultant at the Division of Immunizations, Pennsylvania Department of Health. The consultant has provided a series of free patient education videos designed to dispel the myths surrounding immunization for use in waiting or exam rooms. This patient education information has been loaded onto PORH’s quality improvement (QI) website.

All Pennsylvania CAHs seek to improve Hospital-Acquired Infections (HAI) measures through active participation in the QualityNet Program through the Centers for Medicare & Medicaid Services (CMS) as well as all the Medicare Beneficiary Quality Improvement Project (MBQIP), Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Emergency Department Transfer Communication (EDTC) programs. The three HAIs that are most relevant to CAHs in Pennsylvania are Clostridium difficile, Methicillin-resistant Staphylococcus aureus (MRSA) and catheter-associated urinary tract infection (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. The Pennsylvania Flex Program continues to work closely with quality and infection control experts from HAP.

PORH has developed a website for the CAH QI Directors to have access to a wide range of QI resources. QI conference calls are held quarterly with the QI Directors and quarterly face-to-face meetings are held in the intervening months. PORH’s QI Coordinator meets with new QI Directors to educate them on the QI process. These calls and meetings facilitate discussion on QI initiatives and shared learning. A QI Resource Manual has been developed and is available on the QI website.

Please share a success story about reporting quality data or using quality data to help CAHs in your state improve patient care.

Our success story features Bucktail Medical Center (BMC), which has recently emerged from bankruptcy. The hospital leadership has demonstrated significant improvement in quality of patient care through numerous interventions.

To help alleviate the nursing and staff shortage, PORH facilitated an introduction to staff from the Pennsylvania Primary Care Career Center which will assist in identifying clinicians. In addition, BMC is collaborating with colleges and universities with nursing and medical programs in the following ways:

  • Providing housing for locums and agency staff
  • Hired a Registered Nurse (RN) for their long-term care facility
  • Hired a part-time Licensed Practical Nurse (LPN)
  • Continue to research innovative ideas to help increase staff
  • Continue to work with current staff on retention
  • Continue to advertise in local newspapers for staff

To improve care transitions in the emergency department, activities include:

  • Utilizing the newly purchased iSTAT lab equipment to produce timely laboratory results, which facilitates early recognition of life-threatening conditions for prompt treatment
  • Obtaining a CT scanner to obtain images that may appropriately reveal internal medical conditions (in progress)
  • Collaborating with emergency medical services (EMS) and Life Flight for seamless process of emergent transfers to acute care facilities
  • Significantly decreasing hospital readmission rates
  • Increasing long-term care census through the improvement of quality of care initiatives and marketing strategies
  • Improved communication with the area’s EMS providers by providing EMS continuing education classes held at the hospital
  • Developing a protocol to facilitate effective communication and collaboration among the area’s EMS providers
  • Providing education on heart care protocols, raising awareness of BMC’s ability to treat these patients with lifesaving medical interventions that maximize optimal patient outcomes until the patient can be safely transported via Life Flight or ambulance to an acute care facility

To improve infrastructure, BMC has initiated the following:

  • Held a 'facility improvement day' where members of a local company donated resources to paint and renovate the hallways and desks at the nurse’s station and patient registration
  • Renovation for a new CT scanner
  • Continue to keep the facility clean and free from cluttered hallways

To improve community engagement, BMC held an open house in November and continues to have open forum meetings with the community.

Program Area: Support for Financial and Operational Improvement

PORH provides the CAHs with a wide range of resources, including:

  • Development of ideas for continued hospital viability
  • Vendor information o the restructuring of hospital billing and coding departments
  • Reviewing and maximizing contractual agreements with insurance companies and third-party payers

The state’s CAHs continue to benchmark their financial and quality metrics against other CAHs and 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 will provide the service to the Pennsylvania CAHs to collect and analyze their Medicaid cost reports prior to submission to the state’s Medicaid agency so that the CAHs will receive a Medicaid supplemental (based upon 101 percent reimbursement). The average supplemental per hospital is over $1.75 million. 

An area for improvement this current program year is to improve the operations of the CAHs' affiliated primary care practices. The September 2016 CAH Quarterly Meeting focused on value-based payment strategies for primary care. The November 2016 CAH Quarterly Meeting included presentations by the Pennsylvania Department of Health on the Global Budget Model for Rural Hospitals in the state.

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

PORH is one of the primary stakeholders participating with the Pennsylvania Department of Health’s State Health Innovation Plan (HIP). PORH staff, including the Flex Coordinator, serve on the Population Health Workgroup and co-chair the Health Information Technology Advisory Committee. 

Several CAHs and other rural hospitals are participating in Rural Global Budget Model in the Pennsylvania Rural Health Transformation Plan.  

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. CAHs will 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 Community Health Solution interactive website allows CAHs to view county data for nearly 100 measures of health and socio-demographic data and permits comparisons with national standards such as Healthy People 2020. CAHs are able to easily access this data from the PORH website. Pennsylvania currently has data for 12 counties in the state. The Healthy Communities Institute (HCI), in addition to displaying health data, also provides a comprehensive list of best practices to improve the health of the community. Penn State graduate students continue to assist the counties engaged in the HCI initiative in selecting and implementing a health improvement project based on the health data. Baseline data will be established for each project and a system put in place for monitoring the anticipated change in the health metrics.

PORH is collaborating 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 CAH being designated in November 2016. Two others have expressed interest in beginning the process. Two other rural hospitals have previously been designated as Level IV trauma centers. Efforts will be on-going to have these hospitals 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.

The Pennsylvania Opioid and Narcotic Challenge includes:

  • Assisting CAHs in developing innovative policies and procedures to decrease opioid prescribing
  • A Guideline for Chronic Pain Management in the Emergency Department
  • Working with other health care entities and scholars to develop innovative ways to combat this issue
  • Working with other area clinics to determine the most effective way to help the patients who are addicted
  • Helping CAHs identify steps to track all narcotic prescriptions that are prescribed in their hospital

To improving obstetric care in the ED, the Pennsylvania Flex Program:

  • Assists CAHS in developing policies and procedures to facilitate optimal outcomes for the mother and newborn
  • Continues to work with EMS and Life Flight on obstetric competencies for all ED staff and continued commitment to be adequately prepared for obstetric emergencies

Please provide information about Collaboration/Shared Services

PORH has collaborated with the Health Promotion Council (HPC) to better equip CAHs with the resources and tools they need 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 some of 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 and delivery systems and health insurers/payers. PA CCI consists of multiple components in various health care sectors to accomplish its work. At the CAH Quarterly Meeting in October 2017, HPC presented the program and are assisting the CAHs in developing the program in their hospitals.

Program Area: Support for Designation of CAHs

PORH advises inquiring hospitals on the CAH designation process and provides a preliminary review of their geographic qualifications. A contact is then made with the Region III Office of CMS to confirm eligibility. If eligible, a financial feasibility assessment is coordinated and funded. Other agencies that are involved in the survey and certification process are then contacted.

Program Area: Support for Integration of Innovative Health Care Models

PORH has committed resources to population health and can serve as a resource to the other member organizations. Focus areas for the Pennsylvania Flex Program include:

  • More complex data analysis and visualization
  • Development of a comprehensive approach for small health systems to develop targeted interventions on identified population health issues

With Pennsylvania considering alternate payment models (global budgeting) for rural providers, the 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.

PORH is partnering with Stroudwater Associates on a “Cost Master” program with four pilot CAHs to help them determine their actual costs for specific service lines. The informational kickoff for the project occurred in February 2016, and a subsequent webinar with the four participating pilot hospitals held in April 2016. Each hospital agreed to send their cost reports, when available, to Stroudwater Associates for analysis. Subsequent meetings with the pilot hospitals will begin on a regular basis once the initial analysis is completed. Updates to the state’s CAHs will occur at the quarterly meetings of the Pennsylvania CAH Consortium. The goal will be for the pilot hospitals to have a completed Cost Master by May 2018 with roll out to other CAHs to follow.

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

The Pennsylvania CAH Consortium meets on a quarterly basis with specific meetings focusing on financial performance and quality improvement.

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

Several years ago, the SORHs in Pennsylvania and New York coordinated a joint meeting of their states’ CAHs. Pennsylvania Flex is exploring that possibility for 2018.

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

The Healthy Communities Institute provides population health data for a cohort of rural counties. Information is located on the PORH website. Hospital Strength Index data has focused the Pennsylvania CAHs' outpatient market share. A group of Penn State graduate students did an assessment of two CAHs' outpatient services.  

Please share any resources or tools that you found useful in your state Flex Program's work this past year that you would recommend to your Flex Program colleagues.

The efforts that revolve around the Medicaid Supplemental Program would certainly be considered most valuable by the CAHs. Due to a Commonwealth budget crisis this past fiscal year, PORH, the CAHs and HAP came together to impress upon state government the importance of the Medicaid Supplemental Program for the survival of the CAHs. The program generates on average just over $1 million per CAH. For most of the CAHs, this is the difference in a positive bottom line. Each fiscal year funded by the Flex Program the CAHs submit their MA 336 cost reports for review and subsequent submission to the Commonwealth's Medicaid agency. PORH and HAP work with the legislature to include the supplemental payment into the budget each year.

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.