Each state was asked to provide information about network activities that support Flex Program activities (such as financial improvement networks, CAH quality networks, operational improvement with CEOs or EHR workgroups). The responses are listed below.
The RQN has been meeting since October 2009 and remains the favorite activity of the Flex/SHIP hospitals. The RQN has grown from presenting information to processing data and providing improvement practices. Twenty-eight hospitals are currently participating in the RQN. Participants appreciate the "take home" items provided, such as specifics on how to improve core measures and how to reduce readmission rates.The FIN began in December 2013, and data already exists to show improvements in some financial indicators being measured and promoted, such as net patient revenue, net accounts receivable and days cash on hand. The FIN is a crucial Flex activity to help hospitals improve financial management and sustainability, as six small, rural hospitals have closed in Alabama since 2009.
Since the inception of the FIN, existing data show improvements in some financial indicators being measured and promoted, such as net patient revenue, net accounts receivable and days cash on hand.
Both networks are made up of CAHs and other rural providers who agree to share their respective data with the network. Sharing is critical, as professional consultation provides benchmarking and the sharing of best practices and improvement tools. Both networks focus on specific activities within the Flex Program areas and on areas of mutual concern.View Alabama's State Flex Profile >
The hospitals in Alaska are involved in three informal networks:
- QI involving the Chief Nursing Officers (CNOs) as the leaders and the QI from the hospitals
- Operational improvement involving the CEOs
- Financial improvement involving the CFOs
The networks have monthly teleconferences and two in-person meetings per year where they can discuss best practices and share challenges.View Alaska's State Flex Profile >
AzFlex runs a variety of networks. The networks include a Leadership Network, Quality Network, Trauma Program Managers Workgroup, Strategic Quality Support System (SQSS), Billing and Coding as well as electronic health record (EHR) workgroup specific to a EHR vendor. Most of the networks meet face to face and or by webinar and some networks were set up as a listserve to communicate messages or issues in a fast productive way. All of the above networks have proven to be extremely valuable for the CAHs to network and share information.View Arizona's State Flex Profile >
In an effort to establish and maintain current best medical practices, and to better serve local patients, a health alliance has been formed which includes several of the Arkansas CAHs. One of the programs within the alliance offers onsite health literacy training and access to free chronic disease and stroke continuing education for hospital staff. By utilizing the educational expertise of a state university and the telehealth capabilities of the service area, other training programs have been offered including onsite simulation training for rural hospital teams for obstetric emergency situations and Neonatal Resuscitation Program (NRP) certification training to hospital delivery teams. Additional funding was obtained that offered free, onsite trauma simulation training to CAH Emergency Department staff.View Arkansas's State Flex Profile >
- The iCARE project brings hospitals and their provider based clinics together to help improve communication and readmissions. Currently, CRHC has 23 CAHs and 32 clinics participating in the project
- CRHC hosts monthly webinars where data is examined and best practices discussed. The webinars are a great forum for peer learning and provide the opportunity for facilities to hear from one another what they have been working on, what has been working well and where they may have encountered barriers
- CRHC holds Regional Quality Improvement Workshops each year. They are repeated in multiple locations in an effort to mitigate the distance each facility has to travel. Topics include quality improvement methodologies as well as education and training for MBQIP data submission and analysis
- CRHC manages the CAH Peer Review Network in an effort to provide objective rural providers chart reviewers from other CAHs who have an understanding of the unique working conditions of rural providers
- CRHC also manages a Financial Workgroup where quarterly webinars with CAH CEOs and CFOs are able to discuss/learn the latest financial trends and any new regulations
- CRHC, in partnership with the state quality improvement organization (QIO), hosts bi-monthly CAH Quality Network Webinars that focus on utilizing quality improvement methodologies to build capacity for MBQIP measure reporting and improving data
Florida has small group meetings with the CEOs and key staff at each of the CAHs in the state.View Florida's State Flex Profile >
Hawaii has a quality improvement network and a financial network that meets quarterly to evaluate measures, opportunities for improvement and participate in training for improvement. These meetings also allow the hospitals to ask questions and share areas of difficulty. Hawaii also has a leadership network that provides training to three hospitals on Studer principles and seeks to develop the participating hospitals into Centers of Excellence that can provide training to other facilities that currently are not participating in the network.View Hawaii's State Flex Profile >
All Idaho CAHs interested in forming cohorts around similar MBQIP measures have an opportunity to submit an application for a quality improvement cohort initiative. Every application is reviewed and scored by an impartial Flex Advisory Committee. One competitive application was awarded this year and focused on MBQIP-related quality improvement measures. The CAH cohort is required to establish baseline data and targets for the quality improvement efforts focused on selected MBQIP additional measures. This year three initiatives were awarded:
- The four CAHs in the St. Luke’s Health System (Elmore, Jerome, McCall and Wood River) are implementing a quality improvement project to improve EDTC outcomes
- The Hospital Cooperative has 11 CAHs in southeastern Idaho working to develop an antimicrobial stewardship program in each facility to reduce health care acquired infections in Montpelier, Blackfoot, Soda Springs, Preston, Arco, Rupert, Malad, Gooding, American Falls, Salmon and Driggs
- Weiser Memorial Hospital and Valor Health are also working together to implement antimicrobial stewardship programs in their respective communities of Weiser and Emmett Idaho
The information and best practices gathered from these cohorts will inform future trainings and be shared during site visits.View Idaho's State Flex Profile >
The ICAHN began as a 501(c)(3) not-for-profit corporation in 2003 and now comprises all 51 CAHs, along with four small rural facilities. ICAHN has created a number of cost effective hospital services based on member need, such as rural recruitment, access to group purchasing, HCAHPS, external peer review, CHNA, rural nurse preceptor training, wellness coordination and programming, education and training, information technology (IT) technical support, and access to managed care contracting, coding and other shared services. ICAHN hosts 16 peer network groups and has more than 45 listservs. ICAHN manages the MBQIP and the benchmarking system program. In June 2014, ICAHN established the IRCCO as an LLC and submitted a Medicare Shared Savings Program (MSSP) application to the Centers for Medicare & Medicaid Services (CMS), which was approved on November 18, 2014. There are 23 CAHs and one rural hospital participating in the IRCCO program. In addition, Illinois CAHs will have an opportunity, through IRCCO, to participate in Blue Cross Blue Shield's Intensive Medical Home/care coordination program, beginning April 2015.View Illinois's State Flex Profile >
The Flex Quality Network Council meets every other month via webinar to provide CAH quality staff updates on MBQIP, share best practices and provide updates from the quality improvement organization (QIO).View Indiana's State Flex Profile >
The Iowa Flex Program subcontracted to a technical expert to promote and improve the reporting of quality of care data by CAHs.View Iowa's State Flex Profile >
Kansas state statutes require that all CAHs are part of a rural health network, which is defined as "an alliance of members including at least one CAH and at least one other hospital which has developed a comprehensive plan submitted to and approved by the secretary of health and environment units regarding patient referral and transfer, the provision of emergency and non-emergency transportation among members, the development of a network-wide emergency services plan and the development of a plan for sharing patient information and services between hospital members concerning medical staff credentialing, risk management, quality assurance and peer review." As such, the Flex Program has approximately one dozen state-designated rural health networks across Kansas who provide various levels of service to the CAHs. More information can be found at http://krhop.net/cahs_networks.phpView Kansas's State Flex Profile >
Kentucky works with several rural health networks across the state in a variety of capacities. Please contact Kayla Combs for more information. The state works with a variety of horizontal and vertical networks.View Kentucky's State Flex Profile >
The Maine Flex Program brings together various networks including a CEO Network, CNO Network, CFO Network, Quality Director Network and Nurse Manager Network. All are comprised of CAH staff in specific functional roles (which determines the network in which they participate). Additionally, the Rural Health and Primary Care Program staff and a Maine Hospital Association staff member participate in the CEO and CFO networks. These networks serve as unique arenas for Maine CAHs to come together as a group, discuss their challenges in the CAH realm and share best practices, network and identify projects to engage with as a group. The high level of sharing that happens in these Networks (and the lack of competition between CAHs) gives purpose to the Flex Program.View Maine's State Flex Profile >
Massachusetts Rural Hospital CEO/CFO Forum
This is a learning and action network consisting of CAHs and small rural hospitals, as well as a collaboration with the Massachusetts Hospital Association and it is facilitated (along with core presentations plus ongoing benchmarking activities) by a financial consulting firm. This group participates in group learning, shares best practices and identifies common challenges. It meets in person three times a year, with teleconferencing and emailing, as well as assessments at selected hospitals, in between sessions. Among other things, this group assists hospitals in their transformation to value-based care and in best practices in working with their larger health system, as applicable.
Massachusetts Rural Hospital QI Network
This group is also composed of CAHs and small rural hospitals and includes a collaboration with the state QIN-QIO. This group also meets in person two to three times per year with additional scheduled project-focused teleconferences and speakers.
The state has had an ongoing Massachusetts Rural Hospital Pharmacy Network for many years, but it is now activated on an ad-hoc project basis, since Massachusetts has lost a long-standing collaborative partner, the Massachusetts College of Pharmacy, due to key leadership changes at their institution. The Massachusetts Flex Program has successfully collaborated on multiple projects with the Institute for Safe Medication Practices (ISMP) via the pharmacy network and highly recommends working with this group.View Massachusetts's State Flex Profile >
Michigan has the MICAH QN. All 36 CAHs in Michigan, including three prospective payment system (PPS) hospitals, belong to the MICAH QN. They are a 501(c)(3) organization and members attend quarterly quality meetings and communicate with each other via listserv. Composition of the Network includes Directors of Nursing (DON), quality directors, patient safety managers, hospital administrators and managers.View Michigan's State Flex Profile >
The Minnesota Flex Program Financial Analyst participates as a consultant on monthly calls with Minnesota Department of Human Services. Participants on the call are rural health clinics (RHCs), focusing on billing processes to receive the full PPS rate. Minnesota currently has 87 RHCs, and almost all of them are provider-based attached to a CAH. Minnesota has approximately 33 CAHs with RHCs. Most of the CAHs with RHCs participate on this call.
The Flex Coordinator manages a Google Group called CAH Talk for CAH clinical leaders. This online networking has proven to be very popular with Directors of Nursing, Quality Directors and other clinical staff. They can post questions asking for advice from each other, share best practices, policies and procedures, share resources, etc. It provides CAH clinical leaders easy access to peers throughout the state. Additionally, it frees up time for the Flex Coordinator who might otherwise be fielding their questions and spending a lot of time seeking answers or resources that they can now easily get from one another. The Flex Coordinator does not post on this group except in rare circumstances where there might be something posted that is misleading or needs further explanation, or if a question is directed directly at the coordinator.View Minnesota's State Flex Profile >
MS SORH will subcontract to provide three financial network meetings to share best practices and provide education on the transition to value-based purchasing. This activity will be measured by change in days in accounts receivables.View Mississippi's State Flex Profile >
MHA hosts a CAH CEO Network meeting monthly. This forum is used to decide what activities the Flex activities should focus on as well as identifying needs of the CAHs.View Missouri's State Flex Profile >
The PIN is a long-time established network for performance improvement in Montana. All Flex Program activities in the state are coordinated through the PIN which is comprised of all 48 Montana CAHs. Network activities are supported through a PIN listserv, website and regional meetings. This grant year, the primary focus is on cohort work, having hospitals with similar needs work on projects, sharing the results and processes with the PIN. The Montana Flex Program is also collaborating with CAH financial officers to expand a financial improvement network in the coming year.View Montana's State Flex Profile >
The Nebraska Flex Program uses six CAH networks which range in size from two to 26 members. The networks consist of CAHs and one large regional or urban hospital. The networks hold regular meetings with member CAHs to share information and identify technical assistance needs. Each network has one to two network coordinators that lead the process. The network coordinators all participate in quarterly Network Coordinator Meetings facilitated by Flex staff. The purpose of these meetings is to network, share best practices and information and identify technical assistance needs. The Flex Program sponsors and the Quality Steering Committee to monitor all things quality. Regular meetings are held to review current data submissions, identify technical assistance needs and share best practices.View Nebraska's State Flex Profile >
For over a decade, Flex funding has been utilized to support a QI network that meets quarterly to develop hospital-level and network-based strategies to increase quality reporting and to utilize quality and patient safety data to improve the quality of care provided by Nevada's rural and frontier hospitals.View Nevada's State Flex Profile >
The Flex Program works closely with the New Hampshire Rural Health Coalition including monthly meetings to share critical information, obtain feedback from CAH CEO/Presidents and participate in shared decision making regarding the support provided by the Flex Program.View New Hampshire's State Flex Profile >
New Mexico has a strong Small Rural Hospital Network where CEO's meet face-to-face on a quarterly basis. Leadership staff meet with each other over the phone to discuss best practices and areas of concern. NMHA has been contracted to bring together the quality directors of the hospitals on a visual conference call so they can start discussing best practices. The Small Rural Hospital Network has also brought together the Chief Financial Officers (CFOs) to work on financial improvements for the hospitals, and they are sharing financial data and best practices on a regular basis.View New Mexico's State Flex Profile >
The work of North Carolina's Flex Program creates three LANs that foster CAH collaboration and education. These LANs will meet quarterly to discuss quality improvement initiatives, financial and operational improvement and population health management.View North Carolina's State Flex Profile >
The North Dakota CAH Network serves as a common platform for the CAHs to share best practices, tools and resources related to providing quality of care. The mission of the Network is to support ongoing performance improvement. Goals of the Network include improving information sharing and networking at the regional and state level among CAHs, tertiary facilities and other stakeholders to prevent duplication of efforts. All of the 36 CAHs are members of the Network. An executive committee of CAH representatives serve as a decision-making body and provide leadership to the members and oversight of the Network's efforts. A stakeholder committee, represented by statewide partner organizations, provides feedback and a link to increase communication.View North Dakota's State Flex Profile >
The Ohio Flex Program created the QI Network in 2004, and it has grown and maintained momentum and continued participation. The QI Network focuses on quality, financial and operational improvement through training and technical assistance. There are over fifty-five participants that include chief executive officers, chief financial officers, directors' of nursing and other quality staff in the 33 CAHs in Ohio.View Ohio's State Flex Profile >
In addition to the work with PTSF, the Pennsylvania Flex Program works with a number of other state agencies to help support the CAHs. The HAP is a valuable partner in advocating for the Medicaid Supplemental funding for the CAHs. HAP is also invited to the quality improvement meetings to update the CAHs on the Hospital Engagement Networks in the state. Both the Pennsylvania Academy of Family Physicians and the Pennsylvania Association for Community Health Centers are value partners in assisting with the Primary Care workforce. PORH also serves on the eHealth Partnership Authority committee for safety net providers in the Commonwealth for health information exchange.View Pennsylvania's State Flex Profile >
There are six RHNs in South Carolina comprised of vertical network members, including CAHs, small rural hospitals, rural health clinics (RHCs), federally qualified health centers (FQHCs), technical colleges, mental health and substance abuse treatment providers and local human service coordinating agencies. These networks meet monthly and work toward improving access to quality health care in their communities. In addition, there are two informal CAH workgroups that meet quarterly: one that is quality focused for Chief Nursing Officers (CNOs) and Quality Directors and one that is finance focused for Chief Executive Officers (CEOs) and Chief Financial Officers (CFOs). The two workgroups have one annual meeting each year to network, discuss their individual workgroup outputs and to get Flex Program updates. There is also a South Carolina Small Rural Hospital Improvement Grant Program (SHIP) Network, which includes all five CAHs plus three other small rural hospitals. This network is focused on financial benchmarking and ICD-10 implementation, which is coordinated with the Flex Program Operational and Financial Improvement program area.View South Carolina's State Flex Profile >
- The South Dakota Office of Rural Health has convened a Quality Improvement Collaborative. Members of this collaborative include the state’s rural hospitals, hospital association, quality improvement organization (QIO) and three hospital systems
- The Flex Program actively partners with SDHFMA. Membership in SDHFMA includes the state’s CAHs, the hospital systems and the state hospital association
- A Trauma Council has been convened. The State Trauma Council partners with the Departments of Health and Public Safety in the development and implementation of the Statewide Trauma System. Members of the State Trauma Council represent statewide stakeholders across the continuum of trauma services that include the state hospital association, the state’s hospital systems, trauma surgeons, ambulance services and community/patient representatives
Through their quality improvement (QI) vendor, the Texas Flex Program developed a CAHQI initiative, which will continue in the current funding cycle. In addition to the CAHQI Initiative, there will be six hospitals participating in a Rapid Cycle Team. The six hospitals that are selected will receive more in-depth technical assistance with a short term goal of demonstrating five percent improvement in overall MBQIP measures by three out of the six participants.
In the financial and operational improvement project, 10 hospitals will form two networks that will be located in different parts of Texas. Forming networks last year was successful and the Texas Flex Program decided to duplicate the project this year with a new set of hospitals to participate. Besides the goal of improving the financial and operational outlook of participating hospitals, cultivating relationships is a goal that was successfully met during the last funding cycle.View Texas's State Flex Profile >
A formal network of the nine rural independent hospitals in the state was organized in 2013. The network has articles of incorporation and by-laws, with the board chair position filled by a hospital chief executive officer (CEO). The Flex program works closely with this group to help advance programs and projects that take advantage of economies of scale with nine hospitals as a group, versus each hospital alone. There have been successful programs implemented to help this group of hospitals, mainly along the lines of financial and operational improvement. For example, the hospitals entered into an agreement with a law firm in the state to provide unlimited initial legal advice and assistance for a nominal monthly fee. Other programs include a common insurance broker for property insurance, mobile MRI and GPO services. Subgroups have been formed to network and share best practices, including nurse leaders, human resource managers and quality coordinators. The network continues to grow and has taken on a part-time Executive Director.View Utah's State Flex Profile >
CAH Quality Network: Vermont Flex continues to work with VPQHC to manage a quality network of quality directors and staff from the state's eight CAHs and one additional SHIP-eligible hospital. The Network meet periodically to share information about collecting and reporting MBQIP measures and other quality improvement issues. In November 2016, guest speaker Karla Weng, Senior Program Manager, from Rural Quality Improvement Technical Assistance (RQITA), Stratis Health, presented on all four MBQIP domains as well as trends in quality reporting.View Vermont's State Flex Profile >
The Virginia CAH Network provides a forum for interactive CAH trainings. Some CAH leaders have expressed their lack of time to engage in research to stay abreast of constantly occurring policy changes. Hospital administrators say they want these sessions to continue to provide them with a means to access this information that is vital to their ongoing existence. A contractor provides quarterly metrics regarding network activities.
The Virginia SORH maintains its relationship with the Virginia Rural Health Association to maintain consistent interactions with key rural partners with the intended outcome of improving activities and working together to maintain a finger on the pulse of rural Virginia’s key priorities. The value of this relationship is measured by the growing number of statewide rural partners connecting with the SORH.
The SORH maintains a partnership with the United Way of Greater Richmond and Petersburg (UW), which is measured by whether the UW board adopts recommended concepts of community engagement and collaboration among leaders throughout the region.
The Virginia Rural Work Group is a think tank regarding improving determinants of health for all rural Virginians from a policy and legislative perspective. The SORH recommended the development of legislation language be added to the Virginia Code designating all Virginia CAHs as “located in rural areas” of the Commonwealth of Virginia.View Virginia's State Flex Profile >
The Flex Program funds Washington state networks, WRHC and Washington Rural Health Network (WRHN), in developing the use of the QHi reporting portal among their CAH members. This allows both QI and financial data to be entered and extracted, stimulating conversation around improvements as they compare their performance with other CAHs in their group. Many improvement projects have initiated from this comparison and conversation.
Washington Rural Health Collaborative: Twelve CAHs working on clinical quality improvement, financial improvement and accountable care organization (ACO) development. All but one CAH is on the west side of the state.
Northwest Rural Health Network: This network includes 14 CAHs and one rural sole community hospital. The network has worked primarily on health information technology (HIT) and care coordination. The network has a CFO group that meets regularly and are looking at developing an ACO. Specifically, the goals include:
- Improve the quality and delivery of both behavioral and primary care health services in four rural counties in eastern Washington
- Strengthen the rural health care system by establishing local public-private partnership organizations in four rural counties in eastern Washington
- Expand impact with shared best practices and results
Public Hospital Joint Operating Board: This board is comprised of 18 hospitals that have an agreement to negotiate joint contracts with health insurers. This group is working on preparing for value-based contracting.
The Washington State Hospital Association (WSHA) provides an online monthly QI Leaders forum bringing in topics of relevance and speakers. This a well-attended forum of great value to CAH QI staff.View Washington's State Flex Profile >
The West Virginia SORH/Flex Program works collaboratively with the WVHA CAH Network on all Flex activities. The West Virginia SORH and Flex Programs work collaboratively with WV Rural Health Association, West Virginia Rural Health Advisory Council and other rural health organizations across the state.View West Virginia's State Flex Profile >
Wisconsin takes part in the following networks: Wisconsin Rural Health Council (led by the Wisconsin Hospital Association), Wisconsin Stroke Coalition, Wisconsin Coordination of Care Advisory Committee, Wisconsin Health Care Coalition Advisory Board and the Wisconsin Rural Health Development Council.View Wisconsin's State Flex Profile >
Current networks in Wyoming are the Wyoming Hospital Association (WHA), Wyoming Primary Care Association (WYPCA), the Wyoming Office of Rural Health, Emergency Medical Services, Behavioral Health and the Office of Health Equity. The use of Roundtable Conferences will continue to be utilized throughout this year for continued opportunities to develop stronger network relationships.View Wyoming's State Flex Profile >