CRITICAL ACCESS HOSPITALS STUDY

Pre-Site Visit Data Collection Instrument

Background
The federal Office of Rural Health Policy (ORHP) is sponsoring a formative evaluation effort of the  federal Rural Hospital Flexibility Program (RHFP). This effort is coordinated through the six rural  research centers affiliated with the ORHP and includes the centers at the Universities of Southern  Maine, Minnesota, North Carolina, Washington and the center located at Project Hope in Washington D.C. In addition, the Rural Policy Research Institute (RUPRI) will also be contributing its expertise in conducting and communicating policy analyses. Each of the centers have collaborated in the development of a broad evaluation design to gather information from a variety of sources including existing data sets as well as informants that have experience in the program's implementation at the national, state, community and facility levels.

Introduction
This data collection instrument represents a key component of the facility- and community-level data  collection effort. This pre-site visit instrument gives us much of the background data we need about the  hospital and its environment that will allow us to prepare better for the hospital site visit. Whereas much of this pre-site visit instrument is quantitative, the site visit will focus on more process-related experiences. A major thrust of the overall evaluation effort is to provide useful and timely feedback to national, state and hospital representatives so that the program may be improved as it unfolds.

Please return the entire data collection instrument to:
Andrew Cameron, Ph.D.
Assistant Professor
Department of Health Policy and Administration
1105-D McGavran-Greenberg Hall, CB# 7400
University of North Carolina
Chapel Hill, NC 27599–7400

Directions for Completing the Attached Forms
In preparation for our site visit, we would appreciate it if you would help us gain insight into your organization by supplying the information requested on the attached pages. You will have an opportunity to discuss any of these items with our team at the time of the site visit.

There are four sections to this data collection instrument. You may want to have different people  complete each section. If you have any questions about completing these forms, please contact Andrew Cameron, Ph.D., assistant professor at the University of North Carolina, 919–966–7373, or by email at andrew_cameron@unc.edu.

PQ-2

Background Information

Blue Page: We have compiled the following information about your hospital from documents available to us. Though we have attempted to enter the correct information before sending it to you, we would appreciate it if you would review the information below to see if it is correct and fill in any blanks and/or make changes when our information is incorrect.

Please enter the approximate date the instrument was completed:

A.    Hospital Description

A–1.    Ownership/Governance

1.    Name of the hospital:
          ____________________________________________________________________

2.    Location (City, State):
          ____________________________________________________________________

3.    Administrator:
          ____________________________________________________________________

4.    Year hospital founded:
          ____________________________________________________________________

5.    If part of a larger system, name of system:
          ____________________________________________________________________

6.    Public, not-for-profit, or for profit:
          ____________________________________________________________________

7.    Has there been a change in ownership or
        leadership within the past 3 years?
          ____________________________________________________________________

8.    Nature and character of the hospital board:
          ____________________________________________________________________

9.    How many members?
          ____________________________________________________________________

10.    Percent residing in community?
          ____________________________________________________________________

11.    How are they selected?
          ____________________________________________________________________

12.    What is the turnover rate?
          ____________________________________________________________________

13.    What is the physician involvement?
          ____________________________________________________________________

A–2.    Hospital's External Environment

14.    Referral partners/partner hospitals in the CAH network:
          ____________________________________________________________________

15.    Top 2 Competitors
          ____________________________________________________________________
          ____________________________________________________________________

16.    Size of target population:
          ____________________________________________________________________

17.    Percent of target population served (i.e., market share):       
          ____________________________________________________________________

A–3.    CAH Timeline

18.    Date application submitted:
          ____________________________________________________________________

19.    Effective date of CAH:
          ____________________________________________________________________

20.    Date cost-based payment started:
          ____________________________________________________________________

A–4.    Participation in Federal/State Programs
This section deals with your hospital's federal and state designation prior to and including your CAH designation status.

21.    Were you previously an EACH/RPCH facility?
          [ ] Yes     [ ] No

22.    Were you designated as a sole community hospital (SCH)?
          [ ] Yes     [ ] No

23.    Were you designated a Medicare dependent hospital (MDH)?
          [ ] Yes     [ ] No

24.    What was your Medicare disproportionate share percent?
          ____________________________________________________________________

25.    What was your Medicaid disproportionate share percent?
          ____________________________________________________________________

PQ-3

A-5. Scope of Services

Current Services

26.    Obstetrics
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

27.    Surgery
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

28.    Intensive care unit
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

29.    Psychiatry
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

30.    Outpatient Department
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

31.    Occasional specialty clinics
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

32.    ER
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

33.    Hospital-based ambulance services (emergency and non-emergency transport)
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

34.    Home Health
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

35.    Inpatient rehabilitation
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

36.    Outpatient rehabilitation
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

37.    Laboratory
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

38.    Radiology – diagnostic (MRI, CAT scan, X-ray, etc.)
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

39.    Radiology – therapeutic
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

40.    Teleradiology
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

41.    Telemedicine/telehealth
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

42.    Satellite clinics
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

43.    Skilled Nursing Facility
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

44.    Swing beds
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

45.    Hospice
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

46.    Durable medical equipment
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

47.    Wellness center
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

48.    Telemetry
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

49.    Other (specify):
          [ ] Presently offered
          [ ] Added within the past 3 years
          [ ] Dropped within the past 3 years
          [ ] Changed as a result of planning for and converting to a CAH

50.    If any of the "dropped services" above were dropped because your system or network partner instead will provide those services for your service area, please note the line numbers (from lines above) of those services here:
          _____
          _____
          _____
          _____
          _____

51.    Top 5 DRGs admitted:
          DRG #s:
          _____
          _____
          _____
          _____
          _____

52.    Top 5 DRGs for treatment costs:
          DRG #s:
          _____
          _____
          _____
          _____
          _____

53.    Top 5 DRGs for days of care (longest ALOS):
          DRG #s:
          _____
          _____
          _____
          _____
          _____

PQ-4

B.    Financial and Utilization Information

B–1.    Emergency Room

1.    Have the number of visits to the ER increased or decreased over the past three years?

1997: [ ] Increased  [ ] Decreased [ ] Approx. the same (compared to 1996)
1998: [ ] Increased  [ ] Decreased [ ] Approx. the same (compared to 1997)
1999: [ ] Increased  [ ] Decreased [ ] Approx. the same (compared to 1998)

2.    What are the reasons for changes in the number of visits (if applicable)?
          ____________________________________________________________________

3.    Is there 24-hour ER coverage?
          [ ] Yes      [ ] No

4.    Have the ER's hours of operation changed since CAH conversion? If so, how?
          [ ] Yes      [ ] No

5.    How is the ER staffed?
          [ ] Contracts with local physicians
          [ ] Contracts with PAs
          [ ] Contracts with an emergency physician firm
          [ ] Other:____________________________________________________________

6.    Has the staffing changed since conversion?
          [ ] Yes      [ ] No
       How?
          ____________________________________________________________________

7.    Have ER capabilities changed since CAH conversion?
          [ ] Yes      [ ] No
       If so, how?
         ____________________________________________________________________

8.    What is the relationship with pre-hospital EMS?
         ____________________________________________________________________

B-2. Pre-Hospital Services

EMS Environment in the Hospital's Service Area Prior to CAH Conversion

9.     In the spaces at right, please list the EMS providers (agencies) that served your hospital's service area prior to the time your facility converted to CAH status:
10.     Was the provider government- owned (G) or private (P)? (Circle the appropriate letter.)	G     P	G     P	G     P	G     P
11.     Was the provider hospital-owned (H), fire-service based (F) or did it have some other principal affiliation (O)?	H   F    O	H   F    O	H   F    O	H   F    O
12.     Was the provider's staff predominantly volunteer (V), predominantly paid/career (P), or a mix of volunteer and paid staff (M)?	V   P    M	V   P    M	V   P    M	V   P    M

13.    Did any of the providers listed above have their own paramedics or EMT-Intermediate personnel (i.e., did they provide advanced life support services)?
          [ ] Yes      [ ] No

14.    Was emergency air transport available in your hospital's service area?
          [ ] Yes      [ ] No
         If yes, who provided this service?
          ____________________________________________________________________

PQ-5

Hospital's EMS Situation Prior to CAH Conversion

15.    Before your facility converted to CAH status, did your hospital own or operate an
ambulance service?
          [ ] Yes      [ ] No

• If yes, did this ambulance service provide:
  -->9-1-1 emergency response?
            [ ] Yes      [ ] No
  -->emergency transports between facilities?
            [ ] Yes      [ ] No
  -->non-emergency transports (between facilities and/or patient's home)?
            [ ] Yes      [ ] No
• If no, did your hospital have specific contractual arrangement(s) with EMS        
  transport provider(s)?
            [ ] Yes      [ ] No

16.    Prior to CAH conversion, what agencies provided inter-hospital transport for your facility?
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________

17.    Prior to CAH conversion, did your hospital provide medical direction for local
EMS providers?
          [ ] Yes      [ ] No

18.    Prior to CAH conversion, did your hospital need to provide nurses to accompany critical inter-facility transfers (i.e., to complement the capacity of the pre-hospital system)?
          [ ] Yes      [ ] No

19.    Prior to CAH conversion, did your hospital provide paramedic intercept services for local EMS providers? (Paramedic intercepts occur when a paramedic goes out to meet the transporter to assess the patient and/or accompany the patient to the hospital.)
          [ ] Yes      [ ] No

20.    Prior to CAH conversion, did your hospital bill on behalf of the EMS providers serving the hospital?
          [ ] Yes      [ ] No

• If yes, did your facility bill Medicare for ambulance services?
            [ ] Yes      [ ] No
• If yes, did your facility bill any other payors for ambulance services?
            [ ] Yes      [ ] No

B–3.    Referral Patterns and Relationships

21.    How many transfers of inpatients to another acute care facility for acute care have there been in the past 4 years?
          1996: _______
          1997: _______
          1998: _______
          1999: _______

22.    Has this changed since becoming a CAH?
          [ ] Yes      [ ] No
         If so, why?
          ____________________________________________________________________

23.    How many transfers to other acute care facilities have there been from the ER in the past 4 years?
          1996: _______
          1997: _______
          1998: _______
          1999: _______

24.    Has this changed since becoming a CAH?
          [ ] Yes      [ ] No
         If so, why?

25.    Has the change in the length-of-stay limit from a 96-hour per-case limit to a 96-hour average had any effect on the transfer rates?
          [ ] Yes      [ ] No

26.    With how many referral hospitals do you have written agreements for accepting your patients?
          ____________________________________________________________________

27.    Do specialists come from those hospitals to practice here?
          [ ] Yes      [ ] No

28.    Are there telemedicine/telehealth linkages with referral hospitals?
          [ ] Yes      [ ] No

29.    What are the uses of these telemedicine/telehealth linkages?
          [ ] Education
          [ ] Routine cases
          [ ] Emergent/urgent cases
          [ ] Specialist referral
          [ ] Other: ___________________________________________________________

PQ-6

B.4 Financial Information: Revenues, Expenses, and Balance Sheet Data

When possible, we have entered below financial information about your hospital from documents available to us. If data are filled in below, we would appreciate it if you would review the information and make changes to any incorrect information. Please also fill in the blank cells. We would also appreciate it if you would send us your FY 1998 and 1999 Medicare cost reports and financial statements (statement of operations, balance sheet, statement of changes in net assets, and statement of cash flows).

PQ-7

C.    Community's Health System

C–1.    Providers, practices and clinics

1.    How many private practice physicians, nurse practitioners, physician assistants, and pharmacists practice in this community?
          _____ primary care MDs
          _____ specialists
          _____ nurse practitioners
          _____ physician assistants
          _____ pharmacists

2.    How many physicians, nurse practitioners, and physician assistants practice in public facilities such as community health centers, health departments, and state-supported clinics?
          _____ physicians
          _____ nurse practitioners
          _____ physician assistants

3.    Does the hospital have a close relationship with any of these providers?
          [ ] Yes      [ ] No

4.    Does the hospital provide income guarantees to any of these providers?
          [ ] Yes      [ ] No

5.    Do visiting specialists come to your community to provide outpatient consultations?
          [ ] Yes      [ ] No

6.    If yes, what specialties, how often are the clinics held, and from where do the specialists come?
          Specialty                              Frequency                         From where does
                                                                                            this specialist come?
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________

C–2.    Other Area Resources/Facilities

7.    What agency is responsible for public health services, such as water quality, immunizations, family planning, and infectious diseases? Name of agency, contact name, and phone number:
          ____________________________________________________________________

8.    What skilled nursing facilities (nursing homes) exist in the community?
          Name:______________________________ Town:___________________________
          Name:______________________________ Town:___________________________
          Name:______________________________ Town:___________________________

9.    Are there any certified Rural Health Clinics in your community? Please describe:
          Name of clinic                              Owned by                          # physicians
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________

PQ-8

D. Strategy-Related Information

D-1. Strengths/Problem Areas

Directions: In column 2, please check those areas in column 1 that were MAJOR AREAS OF STRENGTH or MAJOR PROBLEM AREAS of your hospital during the 6 months prior to conversion to CAH status. (Please check ALL that apply) In column 3, please check those areas in column 1 in which your hospital is currently undertaking, or planning within the next 3 years to undertake, a MAJOR INITIATIVE . (Please check ALL that apply)

Information concerning the process leading up to CAH conversion.
Directions: Please fill in the following information.

D–2.    Feasibility Studies

50.    If a financial feasibility study was conducted to study the possibility of CAH designation, please list the name of the firm or agency that conducted the study and the net effect on the bottom line the study estimated.

          Name of firm or agency                                                 Net effect
          _____________________________________________   $____________________
          _____________________________________________   $____________________
          _____________________________________________   $____________________
          _____________________________________________   $____________________

D–3.    Parties Involved in Conversion Decision-Making

51.    Please identify which of the parties in column 1 played a MAJOR role as a supporter (S) or opponent (O) in making the decision to switch to CAH status. Also, please identify which of the parties in column 1 provided MAJOR technical assistance (T) in the decision-making process leading to CAH conversion. Please check all that apply. Please feel free to add other parties in the space provided or on the back of this sheet.

D–4.    Strategic Planning

Please check all that apply.

52.    Does your hospital have a formal, written strategic plan?
          [ ] Yes      [ ] No
If no, you are finished.
If yes, continue to the next question.

A. Who played a major role in developing the strategic plan?
1). The Board
          [ ] Yes      [ ] No
2). The CEO
          [ ] Yes      [ ] No
3). The hospital administrative team
          [ ] Yes      [ ] No
4). Outside consultant:
          [ ] Yes      [ ] No
5). Parent organization:
          [ ] Yes      [ ] No
6). State agency:
          [ ] Yes      [ ] No
7). Other:
          [ ] Yes      [ ] No
8). Other:
          [ ] Yes      [ ] No

B. Does the strategic plan contain any of the following?
1). Mission/Vision
          [ ] Yes      [ ] No
2). External environmental assessment
          [ ] Yes      [ ] No
3). Internal environmental assessment
          [ ] Yes      [ ] No
4). Goals and objectives
          [ ] Yes      [ ] No
5). Measurable goals and objectives
          [ ] Yes      [ ] No

Thank you very much for taking the time to complete this data collection instrument.

Please return the entire data collection instrument to:
Andrew Cameron, Ph.D.
Assistant Professor
Department of Health Policy and Administration
1105-D McGavran-Greenberg Hall, CB# 7400
University of North Carolina
Chapel Hill, NC 27599–7400

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Last updated 20 October 2008 03:43:48 PM -0500
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