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CAH Quality Improvement

The Texas State Office of Rural Health (SORH) contracts with the Texas Hospital Association and Texas A&M Rural and Community Health Institute to provide technical assistance on the Medicare Beneficiary Quality Improvement Project (MBQIP). Technical assistance consisted of two in-person statewide meetings, eight webinars, monthly phone calls, and site visits. Incorporating feedback from critical access hospital (CAH) quality improvement champions, the Texas Flex Program is working on a quality improvement training program and MBQIP Portal.

CAH Operational and Financial Improvement

The SORH, in partnership with their financial and operational contractor – the Texas Organization of Rural and Community Hospitals, selected 16 CAHs by examining various measures, with their confirmed participation. Onsite condition assessments were completed at each of the CAHs and the cohort met on a quarterly basis and focused on out-migration, penetration of Medicare Advantage, Managed Care Organization (MCO) contracts, and a hospital dashboard. Moving forward, they will continue to monitor the participating CAHs to see the impact of the interventions as well as take a statewide approach to provide assistance and support to CAHs. The Texas Flex Program is also excited about utilizing a newly developed hospital dashboard to drive technical assistance, as well as working with a few identified CAHs to provide in-depth onsite consultations. 

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

The state has been divided into six different regions composed of both CAHs and prospective payment systems (PPSs) – all rural hospitals, ranging from 20 to 30 in each region. The regions were developed looking at both formal and informal networks (state-identified regions of services and local rural health networks). The goal is that regions meet quarterly and implement technical assistance through this regional approach. 

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

The SORH supports a collaborative rural hospital stakeholder group that meets bi-monthly. The group originally came together to complete a strategic plan for the Flex grant and has since continued to meet. Members of the collaborative group include hospital administrators, CAH quality improvement champions, contractors, the Quality Innovation Network and Organization (QIN/QIO) for the state, and other state experts. The group is currently exploring sharing more recent state data and aligning technical assistance. The cross-state collaboration will also work on hosting a rural hospital conference.

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

As needs and supports are identified by the rural hospitals and other stakeholders, the Texas SORH will reach out to the identified non-traditional partners to meet identified goals. In the future, they will work on bringing rural emergency medical services (EMS), nursing homes, local foundations, rural health clinics (RHCs), and federally qualified health centers (FQHCs) to the table.

Program Statistics

Do you have any hospitals interested in converting to CAH status?:
Type of Organization State Government
Staffing (FTE) 4
Website Organization Website 
Number of CAHs 86

Flex Program Staff

Trent Engledow
State Office Director, Texas
(512) 463-6121

State Office Director since October 2016

Robert Shaw
Flex Coordinator, Texas
(512) 936-6339

Robert received his undergraduate degree from Texas A&M University and went on to earn a Master of Public Health from Texas A&M Health Science Center. Robert has planned, implemented, and sustained various health and social service programs in rural-community settings ranging from, telehealth (provided free mental health and substance abuse counseling), community health worker program, and home-delivered meal program. Robert has worked on state-wide initiatives and recently provided community development support on a children's mental health initiative. 

Flex Coordinator since July 2018

Trish Rivera
Rural Health Specialist, Texas

Trish Rivera was a licensed social worker in the field of early childhood, child welfare and substance abuse. Trish worked in an early childhood agency for many years and at a residential substance abuse treatment facility that had a program for women with young children.

Rural Health Specialist since October 2019.

Maria Bustamante
Rural Health Specialist, Texas
(512) 475-0793

Maria Bustamante has a business and finance major and worked on it for 20+ years. Maria worked with Quality Improvement for the past five years and is also a certified Community Health Worker in the state of Texas.

Rural Health Specialist since September 2019

Ryan Horsak
Rural Health Specialist, Texas
(512) 463-9639

Rural Health Specialist since February 2020

Kathy Johnston
Rural Health Specialist, Texas
(512) 463-9590
  • Certified Community Health Worker
  • Certified Mental Health First Aid Instructor
  • Worked for Area Health Education Center, Permian Basin, Admin. and Community Liaison
  • Associate of Arts degree

Rural Health Specialist since September 2019

Eva Cruz
Rural Health Specialist, Texas

Eva Cruz has spent 20+ years in County Indigent Health Care Program Management, as well as 10 years in the Detartment of State Health Service Community Health Program Coordination.


Eva began as a Rural Health Specialist in January 2021.

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.