What is a CAH?
A Critical Access Hospital (CAH) is a rural hospital with fewer than 25 acute care beds located at least 35 miles, or 15 by mountainous terrain or secondary roads, from the nearest hospital unless designated as a “Necessary Provider” by a state plan. A CAH is certified to receive cost-based reimbursement from Medicare. The reimbursement that CAHs receive is intended to improve their financial performance and thereby reduce hospital closures.
What is Flex?
The Rural Hospital Flexibility Program (Flex) provides funding to state governments to spur quality and performance improvement activities; stabilize rural hospital finance; and integrate emergency medical services (EMS) into their health care systems. Flex funding encourages the development of cooperative systems of care in rural areas.
Only states with Critical Access Hospitals (CAHs) or potential CAHs are eligible for the Flex program. There are 45 states enrolled in Flex (Connecticut, Delaware, Maryland, New Jersey and Rhode Island do not participate in Flex funding).
The Flex program focuses on four core areas:
Support for Quality Improvement in CAHs
Support for Operational and Financial Improvement in CAHs
Support for Health System Development and Community Engagement, including integrating EMS in regional and local systems of care
Rural Health Networks Prove There Is Strength in Numbers
by Candi Helseth
Rural health networks have captured the attention of health care providers and policymakers as an important strategy for improving access to health care services for rural populations—and for their potential to improve health care quality.
“Rural health networks are definitely documenting improved quality performance,” said Kristin Martinsen, Hospital State Division Director at the federal Office of Rural Health Policy. “Within the area of quality, networks can be a great tool for hospitals to improve outcomes. When these hospitals pool resources to network, those with fewer resources get access to resources they otherwise wouldn’t have. We’re not mandating networks in and of themselves, but networks can help achieve Flex program goals.”
Formed initially to support CAH participation in Flex QI programs, MICAH has branched out to address a variety of QI initiatives, measurements and projects specific to needs specified by CAH members. The Michigan Center for Rural Health (MCRH) and the Michigan Flex Program support MICAH, which is the only state-level nonprofit network solely devoted to CAH quality measurement and improvement issues, according to current President Ed Gamache.
As hospital CEO of Harbor Beach Community Hospital, Gamache personally sees the daily struggles unique to small CAH operations. Once predominantly a logging community on Michigan’s Lake Huron shoreline, Harbor Beach attracts thousands of tourists to its beaches. But only about 6,000 residents live in this area where the 15-bed hospital, with 39 long-term care beds, is more than 1.5 hours away from any of three major tertiary centers.
In Montana, 100 or more miles separate CAHs and seasonal weather conditions can make 10 miles impossible to travel. Staff grapples with limited resources, inadequate budgets and constant workforce turnovers, says PIN Flex Grant Director Carol Bischoff. There’s no time to research, implement and track quality improvement measures because nursing leadership is too busy doing hands-on patient care. PIN helps CAHs with quality improvement efforts and clinical and operational assistance.
As a member of the Montana Rural Healthcare Performance Improvement Network, Livingston HealthCare is one of its CAHs that has involved pediatric care staff in focused education and hands-on procedure skills practice.
Both MICAH and PIN are ahead of the game in quality improvement, having already implemented QI studies and measures related to management of patients with pneumonia and heart care. The Flex Medicare Beneficiary Quality Improvement Project (MBQIP) rolled out in September by ORHP identifies management of pneumonia and heart care as priorities in MBQIP’s first phase. (See related story.)
The networks use quality measure tools to help define processes, outcomes, etc. From the initial collective endeavor to evaluate care provided for community-acquired pneumonia, MICAH’s measurement system now includes 26 quality metrics applicable to rural situations, according to Gamache. Michigan CAHs all have access to a web-based clinical benchmarking reporter.
“By working with all CAHs collectively, data becomes more relevant and performance levels are reflected more accurately as a whole,” Gamache elaborated. “As a result, MICAH can better identify how Michigan CAHs are performing and where improvement needs to be made. And these are rural facility relevant performance measures.”
With a goal of improving emergency care for pediatric patients statewide, PIN collaborated with MT Emergency Medical Services for Children (EMSC) to collect information about pediatric emergencies and document Emergency Department (ED) visits and care in 28 CAHs. Five PIN peer groups submitted baseline and remeasurement data for 422 pediatric cases over a year’s time. After identifying performance improvement goals, PIN involved CAH pediatric care staff in focused education and hands-on procedure skills practice. The study documented performance scales in areas such as patient assessment, medical care and trauma care. Every participating CAH recorded measurable improvements.
“We search for performance standards and national performance benchmarks when we build our studies,” said Kathy Wilcox, PIN Rural Hospital Quality Coordinator. “Our CAHs do a baseline data collection, a re-measurement after six months, and then we define opportunities for improvement. Those go back to the CAH so they see where their performance varied the most compared to national guidelines. They can see peer group and facility performance levels, which gives them two different groups for comparison.”
MICAH and PIN have several additional quality projects underway, and have shared information and collaborated on projects together. MICAH regularly publishes a Best Practices Model on its projects. Network benchmarking gives CAHs solid information about what is working well in other states’ rural communities, Martinsen noted.
Offering Education and Recognition
Education and recognition are essential components for helping CAHs work independently and interdependently. Both networks communicate extensively via websites, telehealth webinars, conference calls, etc. They also sponsor regular face-to-face meetings and have established awards recognition programs. MICAH publishes CMS quality data for public access on the Michigan Health and Hospital Association website.
“Our CAHs are always looking to each other for education and information,” said Angela Emge, MICAH hospital programs manager. “We have a listserv that all of them use extensively. Following our quarterly quality meetings, I send out a newsletter that highlights discussions, decisions made, etc. There’s a lot of communication back and forth. They share documents and educate each other in addition to the education MICAH provides.”
Two Michigan CAHs used professional and public education to improve outcomes for stroke patients. A 2007 data review indicated that patient treatment times were too long from onset of symptoms and that thrombolytics were under-used. Family-specific education, distributed to 30,000 households, was designed to sharpen responses to stroke symptoms and ensure earlier hospital arrival. Professional education centered on thrombolytics education for medical staffs. From 2007 to 2009, average ER arrival time decreased from 327 minutes to 259 minutes. Thrombolytic administration increased from 1.8 percent for all ischemic stroke patients in 2007 to 6.5 percent in 2009.
Expanding Beyond State Lines
In addition to helping increase rural health care access, networks increase the effectiveness of network member institutions, and aid the diffusion of managed care in rural areas, according to Using Rural Health Networks to Address Local Needs: Five Case Studies. Network formations vary widely, some serving certain regions in a state, some statewide and some multi-state.
“I believe we are going to see more networks transcending state lines as they look to work together on joint initiatives and to share products/service lines,” said Sally Trnka, National Rural Health Resource Center Program Coordinator. “I firmly believe that networking is going to be vital to the success and viability of rural hospitals and CAHs. If you look at the way that the reform legislation is worded, we are headed towards a system that requires rural health care facilities to network together to better serve their patient populations.”
What Michigan and Montana have realized is that networks bring together rural providers to address health care problems that could not be solved by any single entity working alone. Gamache said MICAH’s quality network has provided a framework that helps CAHs develop data useful to their performance and the ability to share their successes. Through the use of MICAH developed measures, CAHs can participate now in the Michigan Blue Cross Blue Shield (BCBS) pay for performance program, Gamache said, noting that the program “was historically developed for larger facilities.”
“PIN strengthens the fragile infrastructure of our state’s small rural CAHs,” Bischoff asserted. “We went from these hospitals not knowing anyone in other facilities to literally giving the shirts off their backs to their peers, sharing a tremendous amount of knowledge. And in the process, they also save a tremendous amount of time.”
The Partnership for Patients is a new public-private partnership to help improve the quality, safety and affordability of health care in the United States. Its two goals are to: keep patients from getting injured or sicker; and, help patients heal without complication.
Its nine areas of focus are:
Adverse Drug Events
Catheter-Associated Urinary Tract Infections
Central Line Associated Blood Stream Infections
Injuries from falls and immobility
Obstetrical Adverse Events
Surgical Site Infections
Other Hospital-Acquired Conditions
Currently more than 6,200 partners, including over 2,800 hospitals as well as physicians and nurses groups, consumer groups, and employers, have pledged their commitment to the Partnership. Using as much as $1 billion in new funding provided by the Affordable Care Act (ACA), the Department of Health and Human Services (HHS) will work with a wide variety of public and private partners to achieve the two core goals.
The recently formed Innovation Center at the Center for Medicare and Medicaid Services intends to dedicate over $500 million to test models of safer care delivery and promote implementation of best practices in patient safety. CMS will also provide $500 million for a Community-based Care Transition Program created by the ACA to support hospitals and community based organizations in helping Medicare beneficiaries at high risk for readmission to the hospital safely transition from the hospital to other care settings.
Grande Ronde Hospital, a Critical Access Hospital (CAH) in northeast Oregon.
By implementing TeamSTEPPS, Grande Ronde Hospital, a Critical Access Hospital (CAH) in northeast Oregon, has reduced patient complaints in the Emergency Department by 21 percent and the number of patients leaving ER without being seen by 37 percent.
TeamSTEPPS encourages hospitals to begin with manageable projects, addressing one issue or department at a time. Grande Ronde, located in La Grande, Ore., began by targeting improvements in STEMI (“ST segment elevation myocardial infarction,” a type of heart attack) care in ER. Their data indicated only one-third of patients with STEMI received the recommended administration of an EKG within 10 minutes and thrombolytic medication within 30 minutes of arrival. Using TeamSTEPPS’ tools, Grande Ronde developed a multi disciplinary STEMI team, which pulled together the city-owned emergency medical services and hospital staff from various departments. Now EMS does patient assessments in the field and notifies ER in advance when a patient meets STEMI team activation criteria. The STEMI hospital team assembles in ER, ready to begin treatment as soon as the patient arrives. Current data indicates all STEMI patients receive an EKG within 7 to 10 minutes and thrombolytic administration within 30 minutes or less.
“We have a defined plan of action with people inside and outside the hospital working together, and it’s amazing to see how well it works using TeamSTEPPS communication tools,” Quality/Risk Manager Brandie Manuel said. “It sounds so simple but we had gotten really frustrated trying to find a solution on our own.”
Providing Greater Flexibility and Accessibility
By implementing TeamSTEPPS, Grande Ronde Hospital has increased patient quality in the Emergency Department.
Following a hospital-wide survey of nurses, McCune-Brooks Regional Hospital, a city-owned CAH in Carthage, Missouri, implemented TeamSTEPPS to improve nursing handoff-related events such as medication and intravenous therapy errors. Handoff errors generally occurred between shift changes or when patients were transferred to other floors.
“We’ve decreased handoff events by 8 percent since beginning a year ago,” Chief Nursing Officer Sherry Lopez said. “Our biggest change has been implementing point of care documentation for nurses. We utilize a piece of the patient’s electronic medical record for a patient summary now. All nurses can immediately access that patient information. We have computers in every patient room and nurses do documentation immediately at the bedside. That makes it less likely that medication or procedural related errors happen. It also puts our nurses at the patient’s bedside more rather than in a workroom doing patient records.”
Manuel and Lopez praised the program’s ability to take global terms like leadership and communication and associate them with concrete behaviors and skills in its training materials. Each institution receives a flexible curriculum and training kit they can adapt and modify to fit their particular needs. While basic concepts are uniform, implementation can be different for each organization.
Intensive training is another key to the program’s success. Hospitals send teams to any of five Team Resource Centers for what TeamSTEPPS calls a “train the trainer” approach. These individuals, who become certified as Master Trainers, return to their communities to train others. Trained coaches also mentor and reinforce changes made within hospitals.
Grande Ronde, a member of the Oregon Rural Health Quality Network (ORHQN), collaborated with two other ORHQN CAHs to obtain grant funding that covered training costs at the University of Nebraska Medical Center in Omaha. Primaris evaluated McCune-Brooks’ survey results, provided TeamSTEPPS training at the hospital, and offered additional support in enhancing the patient safety culture, Lopez said. McCune-Brooks completed a hospital-wide survey of staff perception related to patient safety and culture, identified improvement opportunities and presented their findings to hospital leadership to garner support before implementing TeamSTEPPS.
This visual, used in TeamSTEPPS training, illustrates conflict resolution options.
“TeamSTEPPS’ proven tools and its easiness to use encourage administrative and staff buy-in throughout the hospital,” Lopez said.
After an F5 tornado devastated Joplin, Missouri, in May, the Centers for Medicare and Medicaid Service (CMS) granted McCune-Brooks a waiver to accommodate an additional 27 patients and open a third Operating Room. The hospital’s Operating Room volumes almost tripled and the daily census more than doubled from 16 to 37 patients. Lopez said McCune-Brooks operated with existing staff until the end of June when the Talent Share Agreement was implemented with another hospital. Lopez said having the TeamSTEPPS hand-off tool in place helped McCune-Brooks accommodate the increased volumes.
“Under Talent Share, we obtained approximately 150 employees, most of those in the nursing department,” she said. “Their orientation included instruction in TeamSTEPPS tools and the bedside report we are using. We haven’t had an opportunity to do any specific data collection; however, I do believe that if this mechanism were not in place with the increased patient load and new staff, we would have seen an increase in adverse events.”
Influence of TeamSTEPPS Widening
Grande Ronde is developing a 2012 curriculum that encompasses employees in all departments. Manuel said the hospital’s efforts have shifted as they’ve progressed, relying more on coaching and mentoring as needed. “We feel strongly that our entire organization has benefited and it’s important to give all our employees these tools,” she added. “Our non-clinical areas have given us such positive feedback. They feel the training empowered them in ways they didn’t have previously. They really took hold of these tools and changed their processes for the better.”
TeamSTEPPS’ programs are being used in hospitals of all sizes in rural and urban settings. According to Battle, about 2,000 individuals from 700 hospitals have completed training at the five national training centers. The ripple effect has extended the program in immeasurable ways. For instance, with additional funding supplied by the Oregon Office of Rural Health and ORHQN, Manuel said the three CAHs that initially applied for grant funding have since trained staff in 12 additional Oregon CAHs.
A June 2011 policy brief released by the Maine Rural Health Research Center, Improving Hospital Patient Safety Through Teamwork: The Use of TeamSTEPPS in Critical Access Hospitals, concludes that TeamSTEPPS improves processes and reduces errors. “TeamSTEPPS builds a foundation for teamwork that is critical to improving safety and quality,” stated James Battles, PhD, an analyst for AHRQ patient safety who heads the TeamSTEPPS program. “In many community based hospitals, communication lapses or lack of teamwork are underlying factors in adverse events because there is no definitive core team in residence at the facility. Physicians and emergency medical services may be independent from the hospital and, particularly in CAHs, hospital staff may be pulled from different departments for situations such as trauma cases because many CAH emergency rooms do not have 24-hour staffing.”
“The value of TeamSTEPPS is confirmed every day when we hear and see people using these tools,” Manuel said. “At Grande Ronde, we’re going broader now to improve patient safety culture across the entire organization.”
New Project Targets CAH Quality Measures and Reporting
A new project supported by the Office of Rural Health Policy (ORHP) is helping Critical Access Hospitals (CAHs) improve patient care quality and operations, and more accurately report rural health care quality. The Flex Medicare Beneficiary Quality Improvement Project (MBQIP), rolled out in September, will target Flex funding support to CAHs that voluntarily engage in quality improvement (QI) projects meeting its guidelines.
Improving quality has always been one of the primary goals for CAHs participating in the ORHP Medicare Rural Hospital Flexibility Program (Flex), which was begun in 1997 under a federal program to strengthen rural health care. ORHP Senior Health Policy Advisor Paul Moore said the three-phase MBQIP targets those CAHs that haven’t been implementing rural-relevant quality measures or aren’t reporting QI results. CAHs comprise 66 percent of all rural hospitals.
“The first phase initiatives focus on rural appropriate care management protocols,” said Kristin Martinsen, ORHP Hospital-State Flex Division Director. “Congestive heart failure and pneumonia management were our first choices because these diagnoses make up a large part of inpatient admissions in rural hospitals.”
In addition to continuing QI initiatives on Phase 1 measures, MBQIP’s second phase calls for adoption of measurement and reporting for outpatient care along with patient satisfaction, Martinsen said.
“Outpatient procedures are a natural focus because CAHs tend to have a higher volume of outpatient services than inpatient,” she explained. “Patient safety and reducing hospital readmissions are also focuses in the second phase, which begins in September 2012.”
In Phase 3, beginning in September 2013, CAHs will begin measuring and reporting on efforts to reduce medication errors and improve outcomes for patients being transferred to other facilities.
Moore said the third phase offers the best opportunity for CAH QI improvements because adverse drug events or improper medication management is the primary cause of harm in hospitals nationwide. A pharmacist is on-site for less than 40 hours a week in more than one-third of small rural hospitals so the third phase calls for a pharmacist’s review of medication orders within 24 hours. Because many CAH patients are transferred to tertiary centers for surgery or other advanced care not typically offered at CAHs, it is imperative that CAHs conduct transfers using proven, successful measures. Moore said the third phase was slated for 2013 to give participating CAHs ample planning time for the additional resources that will be required.
“We are focusing on improving CAHs through measurement, reporting and targeting proven improvement strategies,” he stressed. “We are trying to proceed in a manner that allows them to see the value in participating as they go.”
More than one-third of the 45 states enrolled in Flex already have established QI committees, programs and benchmarks to evaluate success. Martinsen works directly with state offices of rural health, which provide Flex assistance to their state’s CAHs. The National Rural Health Resource Center manages support and education services through the Flex-funded Technical Assistance and Services Center (TASC).
MBQIP is designed to help CAHs measure QI successes and report results to CMS Hospital Compare or another vendor, Martinsen said. (CAHs are not required to report.) “The trends have shown over time that Hospital Compare outcomes have improved on those measures where we do see reporting,” Martinsen said.
About 70 percent of CAHs in state Flex programs choose to voluntarily report to CMS Hospital Compare on at least one quality-related measure. Reporting has been a source of contention among CAHs, Moore said, due to concerns that reporting systems are based on urban hospital research and fails to account for the differences between rural and urban hospital resources, services and patient volumes.
Quality of Care and Patient Outcomes in Critical Access Rural Hospitals, a report released this year by the Journal of the American Medical Association (JAMA), also calls for CAHs to collect and report data. The JAMA article states that little is known about CAHs’ quality of care or patient outcomes in these geographically isolated hospitals. Moore added that getting CAHs to report results in a timely manner will result in development of reporting statistics that more accurately reflect rural health care quality.
“There are bright spots all across the country where CAHs are doing great things,” he said. “What we’re looking to do now is to fill in the gaps and make it consistent among all providers. The CAHs that are already doing quality projects and tracking them have proven that quality can be improved. Now it’s a matter of disseminating those practices and getting them out into areas where it isn’t being done. On a brighter note, I am happy to tell you that, according to the Flex Monitoring team report, rural hospitals do better than their urban counterparts when it comes to HCAHPS (Hospital Care Quality Information from the Consumer Perspective) patient satisfaction. And links to reimbursement in the future will most likely have a patient-centered focus.”
CAHs already engaged in QI projects relative to MBQIP’s first phase can still join in the second or third phases. To learn more about MBQIP and/or to sign up for it, watch this video, or email Paul Moore, PMoore2@hrsa.gov, or Kristin Martensen, KMartinsen@hrsa.gov.
The Rural Monitor is published by the Rural Assistance Center.
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