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Washington State Department of Health

Top Flex Activities

Program Area: Support for Quality Improvement

The Washington State Flex Program provides support for quality improvement and the Medicare Beneficiary Quality Improvement Project (MBQIP) through continuous data monitoring and evaluation, training and practical application of quality improvement skills and supporting quality improvement initiatives at individual critical access hospitals (CAH). Some of the activities we are conducting in fiscal year (FY) 2018 include:

  • Quality Improvement Request for Applications (QIRFA) – the Washington State Flex Program accepted proposals for QI projects CAHs wanted to conduct at their facilities to improve sets of data they see as a priority. The Washington State Flex Program will be awarding 11 proposals with a small amount of funding to conduct their proposed project as well as full support from Flex staff.
  • Brand New - MBQIP First Time Reporter Training Process and Materials. The Washington State Flex Program is in the second year of streamlining and implementing a process for CAH staff that are new to reporting any part or all of the MBQIP measures. This process will ensure staff are trained within the next full reporting quarter to report MBQIP data to shrink the gap in reporting that develops with staff turnover.
  • Washington State MBQIP Annual Report – This will be the first year the Washington State Flex Program will compose and disseminate a full annual report for CAHs in relation to MBQIP. This report will highlight accomplishments of the State as a whole as well as individual CAHs, network activities, and cohorts. The Washington State Flex Program will also highlight the areas in need of most improvement and how the program can approach these.
  • FY 2017 Technical Assistance (TA) – Provided 300 hours of TA to CAH Staff and Partners. The Washington State Flex Program plan to conduct similar TA hours in FY2018

Program Area: Support for Financial and Operational Improvement

As part of a yearly assessments during CAH site visits and again during an annual chief financial officer (CFO) Summit that was co-sponsored with Washington State Hospital Association (WSHA), the Washington State Flex Program asks what challenges they are having. The Washington State Flex Program learned that many of the hospitals have taken their billing back from an outside billing agency and are now hiring and training billers. Based on recommendations from business office managers and other Flex programs, the Washington State Flex Program has contacted several organizations that do training workshops for billing for Medicare and Medicaid claims. After the RFP period is completed, the Washington State Flex Program plans to provide the workshop twice – on both sides of the state – and provide some scholarship funds if the CAH is coming from a long distance. The Washington State Flex Program will measure outcomes by the number of CAHs that attend the workshops and then after 6 months will inquire if their receivables have increased by enhanced billing methods. 

The Washington Flex Program continues to participate for the 4th year in the Washington Rural Health Access Preservation (WRHAP) Pilot. Many are familiar with what is developing in Pennsylvania and Maryland. Washington State is developing their own payment reform methodology that is unique. The WRHAP workgroup is comprised of the Washington State Hospital Association (WSHA) and the 13 critically fragile CAHs. Interestingly, in 2018 the Health Care Authority (HCA) has dropped out of the group. The workgroup's mission is to assist these CAHs on the brink of closure with preparing for value-based purchasing and alternative payment models. The WRHAP Pilot was created when state law ESHB 2450 was passed unanimously by the Washington State Legislature and signed into law by the Governor in April 2017. Funds were appropriated by the Washington Legislature for two fiscal years and are divided back to the 13 CAHS into two components via management assistance and Medicaid services. As of 2018, this funding was not distributed. Meanwhile, HCA after receiving the green light from CMS, is working on a payment methodology separately from WRHAP. The Centers for Medicare and Medicaid Services (CMS) has instructed HCA that their payment method must be statewide and include all rural hospitals and be budget neutral. The Washington State Flex Program continues to provide support as they work on additional funding methods for our rural hospitals. Success will be measured by the enhanced payment that they will receive in three categories, care management, ER, and behavioral health services.

The Washington Flex Program continued funding for an additional year of Quality Health Indicators (QHi) portal access for all 39 CAHs. Previously, only the CAHs associated with the two rural health hospital networks had access through their memberships, leaving out 14 hospitals who were not eligible. With this new contract, all hospitals are able to post both QI and financial measures. At this time one of the rural health networks, The Rural Health Collaborative that includes 15 CAHs, is using QHi for financial measures.

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

The Washington State Flex Program is continuing into the third year of Population Health projects. This past year, nine CAHs successfully completed their second year of a population health project. These projects are a means for CAHs to develop skills and knowledge that build capacity for the new incentives for care and payment. The initial goal was to provide an opportunity for CAHs to assess the social determinants of health in their community based on data review, select a project that could improve population health, and strategize and collaborate with community partners to ensure the success of the project. The Washington State Flex Program is now opening up the projects to additional CAHs to apply. At the end of each year the hospitals provided a final report showing success and what they achieved and any lessons learned. These reports have helped guide the third year of projects as CAHs shared outcomes and topics of the projects, which in turn has created collaboration between the CAHs when they learn of another CAH doing the same project.

One of the new projects will be on suicide prevention. This is the first one of this topic and the Washington State Flex Program will connecting them to the Department of Health (DOH) Suicide Prevention team so that they will have support as they implement this project in their community. 

The third-year goal will be to continue project engagement with community partners and track progress by developing measurable goals and targets. Some of the population health goals and topics include:

  • improve dental health access;
  • early detection and effective treatment of depression;
  • implement collaborative integrated care to improve behavioral and mental health care;
  • provide high-quality care to rural residents by developing a Social Work Extender Program;
  • develop a housing strategy for homeless and lower income patients;
  • and reduce and prevent diabetes, obesity, and heart disease.

The Washington State Flex Program is continuing the second year of providing payment vouchers for volunteer emergency medical services (EMS) in rural communities. Working with the state Rural EMS section at the Washington State Department of Health (DOH), the Flex team identified that volunteer EMS workers were often unable to complete their testing due to the cost of the National Registry test. With Flex funds, the state was able to purchase EMS, emergency medical technician (EMT) and Advanced EMT (AEMT) vouchers that rural EMS agencies can apply for. This supports Washington Flex's goal of increasing volunteer EMS personnel in rural communities. 

Please provide information about Collaboration/Shared Services 

The Washington Flex Program continues to support the statewide development of a new Stroke Triage Tool initiated in each county through the EMS Regional Councils and local county stroke teams. This will include the development of revised county level protocols. The tool is being introduced in two launches on each side of the state and will include EMS teams as well as prevention, post-acute (home health, rehabilitation in a skilled nursing facility), primary care, and other local community resources.

Program Area: Support for Integration of Innovative Health Care Models 

The Washington Flex Program continues to support the integration of innovative health care models through participation in the WRHAP group and through funding the second year of the population health projects for nine CAHs. In addition, the Washington Flex Program is working with Washington Technology Solutions (WaTech) to develop EMS volunteer recruitment videos.

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

The Washington Flex Program actively participates in the Washington Rural Health Access Preservation workgroup which includes 13 CAHs, the Washington State Hospital Association, the Department of Health, the Health Care Authority, and a national expert in value-based purchasing. The Washington State Flex Program will also repeat the CFO Summit and provide value-based payment (VBP) technical presentations from Certified Public Accountants (CPAs) and consultants. 

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

The Washington Flex Program funds state networks in developing the use of the QHi reporting portal among their CAH members.

The Washington State Flex Program also provides funding to the Washington State Hospital Association to provide an online monthly quality improvement (QI) leaders forum, bringing in topics of relevance and speakers. This a well-attended forum of great value to CAH QI staff.

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. In 2018 they received a Health Resources and Services Administration (HRSA) opioid grant. They will be starting this new project soon and will be working closely with their community organizations as they start the project. In addition, Flex is facilitating their collaboration with the DOH opioid workgroup so that they share resources.

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.

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

The Washington Flex Program is working with their Quality Innovation Network (QIN), Association for Professionals in Infection Control and Epidemiology (APIC) and the Washington State Department of Health (WSDH) Healthcare Acquired Infection Section to develop a new Infection Preventionist (IP) training and professional development program designed specifically for CAHs.

Within the WSDH Office of Rural Health, there is collaboration among the federal Small Rural Hospital Improvement Grant Program (SHIP), State Office of Rural Health (SORH), the Stroke Program, Workforce and J1 Visa program, EMS, and Trauma services.

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

Currently, the Washington State Flex Program is promoting the use of QHi to encourage hospitals to upload their Centers for Medicare and Medicaid Services Abstraction and Reporting Tool (CART) data and analyze it real-time for quality improvement efforts.

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


Program Statistics

Type of Organization State Government
Staffing 2.25 FTEs
Number of CAHs 39
Website URL Organization Website

Flex Program Staff

Pat Justis
State Office Director, Washington
(360) 236-2805

Specialty Areas / Background

Patient-Centered Medical Home Collaboratives both statewide and regional, expertise in quality improvement, primary care pratice transformation, patient safety, patient and employee experience.

State Office Director since August 2014

Lindy Vincent
Flex Coordinator, Washington

Flex Coordinator since March 2016

Danielle Kunkel
Flex Quality Improvement Coordinator, Washington
(360) 236-4863

Flex Quality Improvement Coordinator since August 2016

Bonnie Burlingham
State Office of Rural Health Grant Manager, Washington
(360) 236-2819

Specialty Areas / Background

  • Public and rural health
  • Rural health clinics (RHCs)
  • Strategic planning

Grant Manager since September 2013 

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.