Back to Table of Contents

Rural Hospital Flexibility Program Tracking Project

Appendix B
Content of State Applications

Deborah Duncan
WWAMI Rural Health Research Center, University of Washington

Introduction

This Appendix provides a summary review of the grant proposals submitted by state grantees in the Rural Hospital Flexibility Program (Flex Program). "Year 01" refers to the federal fiscal year that began in the fall of 2000.¹ The proposals reviewed for this chapter report on activities completed in Year 01, and activities proposed for Year 02. Year 02 would be the fiscal year beginning in the fall of 2001. A spreadsheet is attached which provides details for each state by each of the five program goals. The reader should be cautious in interpreting Year 02 figures: we are reporting proposed expenditures, not actual expenditures.

The goals of the Rural Hospital Flexibility grant program are to assist rural hospitals and improve access to health services in rural communities. Specifically, states use grant funds to achieve the following program objectives:

• Develop and implement a state rural health plan with broad collaboration among stakeholders.

• Assist rural hospitals and their communities identify, assess and convert to Critical Access Hospital (CAH) status.

• Support CAHs, providers and communities as they develop and implement rural health networks.

• Support the establishment or expansion of programs to improve and integrate rural emergency medical services (EMS) into rural health networks, especially in communities or regions where CAH designation has occurred or will occur.

• Encourage CAHs in their quality assurance efforts.

Grant funds were made available to any state 1) with at least one hospital located in a non-metropolitan statistical area (non-MSA) county (New Jersey and Rhode Island are not eligible for this program because they have no non-MSA counties); and, 2) that chooses to develop a Flex Program and provide Centers for Medicaid and Medicare Services (CMS), formerly the Health Care Financing Administration (HCFA), with the necessary assurances as described in HCFA guideline materials.

A state's health plan must be approved by CMS in order for its hospitals to be eligible for CAH designation. Forty-eight states have received funds from CMS since 1999 to support the development of a state rural health plan, and most have received additional funding to continue participation in the Flex Program. Only one state participating in the program has not yet had its plan approved, although its approval is expected shortly.

Methods

For purposes of this report, 46 state noncompeting grant proposals were reviewed and summarized by the objective subheads found in the Federal Office of Rural Health Policy's (FORHP's) FY2000 Noncompeting Grant Application (September 1, 2000-August 31, 2001):

• Develop state rural health plan.

• Designation of CAHs in the State.

• Development and Implementation of Rural Health Networks.

• Improvement of EMS Services.

• Quality of Care.

A spreadsheet was created summarizing each state's accomplishments, strategies, and expenditures by goal.

All of the applicants had completed their state plans with one exception (Connecticut). The entity applying for federal funding was either the state's office of rural health, university, or other agency-based center for rural health, or department of health ("grantee"). Thirty-four applicants were offices of rural health based in state departments of health. Five applicants were departments of health, not the offices of rural health, which were based in another agency. Five applicants were university-based offices of rural health. We did not review Nevada's application, as we did not have a copy of it.

Information presented in this report is a summary of the applications, which provided information on the progress, accomplishments and future plans on the above objectives. Overall, there were some strong state proposals that followed the instructions explicitly. However, in general, future goals and program strategies, beyond hospital conversions, were generally unclear in most state applications. This is mostly due to the fact that in Year 01, the majority of states focused efforts on the development of the state rural health plan and CAH conversion. Therefore, the details for the last three objectives were not as clear as for the first two (state plan and CAH designation). It is expected that in subsequent years there will be more effort and thought given to the development and implementation of rural health networks, the improvement of EMS services, and quality of care. Essentially, Year 01 laid the groundwork for the development of more advanced programs in Year 02.

This report also includes a summary of total state expenditures-year-to-date and projected. In most cases, it was not possible to distinguish the amount or allocation of state contributions and/or other funding sources from the reviewed applications. However, it does appear in Year 01 that states used grant funds to leverage interest, support, and commitment on the part of eligible hospitals. 

The largest grants in Year 01 (grants over $650,000) went to MT, MN, NE, WI, OK, TN, ND and KS. The smallest grants (under $300,000) went to LA, VA, MS, NM, MD and CT. The states that got the biggest increases (over $50,000) between Year 01 and Year 02 were NH, IN, OH, MO, WA, NV, GA, KY and FL. The biggest grants in Year 02 went to MT, MN, NE, TN, OK, KS, WI, KY, and ND. The smallest in Year 02 were LA, VA, IN, MS, NM, NH, MD, and CT. Grant requests ranged from $110,000 to $700,000 for the Year 02 cycle. See spreadsheet at the end of this appendix.

Develop State Rural Health Plan

In this section, applicants were asked to describe the vision for rural health in their state and the strategy for reaching the described vision. States that had already submitted a Rural Health Plan to CMS were asked to describe any issues, problems, or other activities that remained unresolved. Applicants were also asked to describe the extent of stakeholder and community participation in the development of the state rural health plan.

Actual state plans were not included with the applications. However, the primary components of most state plans include state profile, a profile of rural hospitals, descriptions of state programs and support and details of the process for CAH implementation. Plans outlined how states will identify CAHs, develop rural health networks, integrate EMS, and improve quality of care. 

State rural health plans provide states an opportunity to assess and identify their state's rural health needs and develop their vision around improving rural health. The degree to which these needs were addressed and in how much detail varies by state. Some states had a comprehensive vision with clear goals and objectives while others were in the formulating, assessing and/or identifying stage. However, for all states the development process of the state rural health plan created interest and momentum for the development of a statewide health improvement plan. 

One example is South Carolina. The interest and activity generated around the development of the plan spurred South Carolina's health care and political leaders to see the importance of developing an overall state health plan that focused on both rural and urban areas. Texas states in its application, "having a roadmap, in the form of a state plan, has been very valuable to all involved. It has a been a resource as we strive to realize our vision of maintaining access to care for rural Texans." These sentiments are echoed in most applications.

The primary activities in Year 01 focused on developing task force and advisory committees as well as monthly meetings, identifying and notifying eligible hospitals about the program, and deciding the best way to implement the plan in the state. In addition, a large portion of funds went to the financial assessment of potential CAH facilities.

Advisory committees were developed in almost every state to support the Flex Program and assist in implementation of the state rural health plan. These committees are composed of representatives from a variety of organizations with an interest in the Flex Program, typically including the state office of rural health, the state hospital association, the rural health association, rural hospitals and providers, and state agencies such as those dealing with survey and licensure. A limited number of states also involved representatives from their fiscal intermediaries, their state's emergency medical services agencies, professional review organizations, house and senate offices, the Governor's office, third party payers, relevant special interest groups and consulting organizations employed by the state. These committees have been charged with assessing the state's rural health needs, interpreting policy and procedures, assisting with designation and certification, promotion, application submission, and related activities. The level of committee involvement and activity varies by state.

Budget Activity

Rural Health Plans -- Total Funds
	Amount Spent So Far in Year 01, as of 5/25/00	Amount Expected to Be Spent for the Full Fiscal Year 01	Projected Amount Proposed to be Spent in Year 02
Number of states	31	28	31
Total	$925,811	$1,186,627	$1,331,447
Per state mean	$23,739	$31,227	$35,985
Median	$8,419	$13,373	$18,764

Note:  Not all states included budget details with dollar amounts.  States excluded from all columns are AR, CT, DE, IL, MS, NC, NE, NJ, NM, NV, OR, PA, RI, TX and UT. Funds include all resources utilized for the project, including those other than the requested Federal grant funds.

There were only nine states with expenditures greater than $50,000 for plan development in Year 01, five of which spent more than $100,000.

States with expenditures greater than $100,000 in Year 01 are: 

• Alabama $179,500

• Kentucky $101,352

• Massachusetts $106,635

• Ohio $112,378

• Washington $133,795

All of the above states focused on activities that targeted getting the health improvement plans off the ground. Alabama, Massachusetts, and Ohio hired consultants to provide expert technical assistance in developing a successful program. Washington said grant monies have "allowed the formation of a policy development process which involves hundreds of stakeholders, a policy paper synthesizing the recommendations, and an economic impact analysis tool for empowering communities to address their local health systems." Eighty-eight percent of Washington's total dollars were spent on the Economic Impact Model.²

These are the fours states with expenditures between $50,000 and $100,000:

• Alaska $66,550

• Minnesota $52,000

• Missouri $70,000

• Tennessee $57,600

Applicants, in general, did not provide detailed expenditure information for Year 01. However, references were made to the broad activities the funds supported. Alaska states that funds have supported the development and activities of its steering committee, which has initiated a plan for CAH identification, developing rural health networks, integrating EMS, and improving quality assurance. In Minnesota, the funds went to planning and developing the state rural health plan. Missouri hired a consulting agency to provide technical assistance and consultation services regarding rural health network development and analysis. Tennessee funds were used for administrative support to develop the plan.

Common goals among states for Budget Year 02 were:

• Revise, refine, implement, and continue development and expansion of the state rural health plan. The majority of states referenced revising their state plan to incorporate Balanced Budget Refinement Act (BBRA) 1999 and state legislation changes.

• Address any state legislative barriers and/or Medicaid's lack of participation in the CAH program.

• Hold regular meetings of advisory committees to review progress.

• Encourage networks to develop strategic health plans.

Some of the specifics from individual states that provide a snapshot of what other states are doing for Year 02 include: 

• Alaska planned to hire a project coordinator to coordinate the Flex Program. Another objective is to develop a community needs assessment and technical assistance guidelines to ensure access to hospital and other care services, development of rural networks and community level decision-making in health system issues. This includes enhancing the data and analysis so communities have information to make informed decisions about the future of their hospitals and other health care.

• Tennessee planned to revise its plan to include strategies for improving rural health networks, EMS service integration, and quality of care, as well as a refined process for designating CAHs in the state. In addition, the revised plan will incorporate legislative and other regulatory changes brought about by the BBRA of 1999 and any new state requirements.

• Arizona planned to revise its plan to focus on improvement of the rural information infrastructure. Components will include: 1) baseline rural health status data; 2) baseline rural health services data; 3) baseline rural EMS data; and 4) baseline rural economic data.

• Florida had the largest of projected expenditures for Year 02 ($248,586). Funds were to cover the cost of a full-time planning specialist, a statewide assessment of local health services, a survey of 28 hospitals, a survey of all primary care physicians, rural health resource inventory, network services survey and a three-day education/planning summit.

• Kentucky planned to spend $160,375. The majority of the funds were to be used to hire three FTEs as part of the Technical Assistance Program. The additional staff were to provide technical assistance for hospitals that wish to complete a financial feasibility study, network development, and community assessment.

The majority of the states' plans were to focus on revising and refining the state plan. However, more time, money, and energy are now being shifted to further the development of the below objectives.

Designation of CAHs in the State

In this section, applicants were asked to explain eligibility criteria for CAH designation in their state and identify the total number of designated and eligible hospitals. States were also asked to identify hospitals that had expressed interest in converting to CAH status, detail their plans for enlisting new communities in the conversion process and the extent of stakeholder and community involvement in this activity. 

All applicants stated how many hospitals were eligible for CAH status in their state as well as how many had converted at the time of grant application submission.

As of May 25, 2000, 191 hospitals in twenty-six states had converted to CAH status and 1,034 were eligible for CAH status. Over half of the 191 CAHs (105) were located in six states: Kansas, Montana, Nebraska, Oklahoma, South Dakota, and Texas. NOTE: The total number of CAHs changes continuously. As of May 1, 2001, there were 401 CAHs. 

Six states were attempting to convert closed hospitals to CAH status and in a few states hospitals closed after converting to CAH.

The state criteria for CAH conversion in most states include all or a mix of:

• CAH financial feasibility analysis.

• Community needs assessment.

• Community education plan.

• EMS plan.

States used a variety of strategies in establishing criteria for designating CAHs and targeting grant funds and other technical assistance. Some states were very inclusive in setting criteria while others were more limiting in how they targeted potential CAHs. Many states have taken advantage of the provision in the federal regulations that allow for the state designation of essential or necessary providers, thereby allowing hospitals that do not meet the federal 35-mile distance-from-another-hospital requirement to participate in the program. This provision has been particularly important for states such as North Carolina and Oklahoma where large numbers of hospitals are distributed throughout comparatively small geographic areas. 

The typical strategy selected by states that adopt an inclusive approach to the program is to broaden the eligibility criteria to allow as many rural hospitals as possible to qualify for conversion to CAH status. These criteria generally involve some standard of demographic, health, or economic hardship when hospitals do not meet the 35-mile distance from another hospital requirement. Typically, a hospital has to be located in an area that has a higher percentage of elderly and/or low income residents than the state average, a higher level of unemployment, a higher death rate from defined leading causes of death, a death rate that exceeds the state average for all causes of death, or a designated shortage area. 

Iowa is the only state with a two-step process to become a CAH. The two-step process was created because hospitals in Iowa typically do not meet the 35-mile federal requirement. First, a hospital must apply to the Iowa Department of Public Health to be a designated necessary provider. Then, once recognized as a necessary provider, the hospital is eligible to be surveyed by the Department of Inspections and Appeals and the State Fire Marshall's Office. 

States vary in the number of criteria that hospitals must meet to be eligible for conversion to a CAH. In Oklahoma, hospitals must meet at least one of their established criteria to be eligible for participation. Wisconsin has taken a tiered approach to designating necessary providers of health care services. Hospitals between 20 and 34 miles apart must satisfy at least two of Wisconsin's established criteria. Hospitals less than 20 miles apart must meet at least five criteria. The approach selected by each state depends on how inclusive it wishes to be, the overall health care infrastructure of the state, and the geographic and physical isolation of their rural areas. Alabama is using state-designated "necessary provider-status" if a hospital meets all federal requirements as well as one of the above demographic requirements.

North Carolina, Texas, and Arkansas have taken the eligibility process a step further by tying CAH participation criteria to defined state policy goals supporting the provision of indigent care and the continued provision of services that otherwise would not exist if the hospital were to close. All these states have expressed their intention to reject a hospital's conversion application if the facility were unwilling to commit to these obligations. None, however, have indicated what they would do if the hospital did not hold to these responsibilities after conversion. 

All states are providing some level of technical assistance to eligible hospitals. Technical assistance provided to CAHs and supporting hospitals typically includes financial feasibility studies, educational workshops; communication "toolkits"; computer support, community needs assessments, policy and procedure development and similar activities. The level of support to CAHs and other rural hospitals varied widely among states. Educational workshops/conferences and informational materials were the primary tools used in enlisting communities. 

Budget Activity

Rural Health Plans -- Total Funds
	Amount Spent So Far in Year 01, as of 5/25/00	Amount Expected to Be Spent for the Full Fiscal Year 01	Projected Amount Proposed to be Spent in Year 02
Number of states	34	37	37
Total	$4,813,891	$5,604,975	$7,119,091
Per state mean	$120,347	$140,124	$182,541
Median	$111,689	$135,250	$135,347

Note: Not all states included budget details with dollar amounts. States excluded from all columns are AR, CT, DE, GA, NJ, NM, NV, OR, PA, RI, UT. Funds include all resources utilized for the project, including those other than the requested Federal grant funds.

In the first year, it appears the largest share of federal grant dollars was devoted to providing technical and financial assistance to hospitals and communities interested in CAH conversion as well as those operating as CAHs. In the second year, most states, like Texas, are focusing less on the application and designation process and more on issues of networking, EMS and quality.

Common goals among states for Budget Year 02 were to provide:

• Technical assistance to potential CAHs.

• Education efforts to enlist communities to convert to the Flex Program.

• Contact with CAHs to facilitate designation.

• Education efforts about the Flex Program and CAH conversion.

• Financial feasibility analysis/data collection for eligible hospitals.

• Review and process of applications.

Some states such as Arizona used a creative approach to increase program awareness. Arizona has a publication, "Arizona Critical Access Hospital Application Packet," that contains a description of the Arizona Flex Program, the CAH designation process, a formalized process of developing rural health networks, and the process to be used by CAH-eligible applicants applying for CAH designation and certification.

Development and Implementation of Rural Health Networks

In this section, it was requested that applicants describe their state networks and current and intended membership as well as the extent of stakeholder and community involvement in this activity. It was stated that the focus of this section should not be on the "definition" of networks because it was already defined in the HCFA grant application guidelines- "a network is a formal agreement between one CAH and one acute care hospital with agreements regarding patient referral, transfer, communications and transportation."

The definition of "network," however, remains elusive. There was no single common theme among the states. Applicants' descriptions of network development were inconsistent. Some applicants chose to focus on the development of EMS networks and recruitment and retention issues. There were many types of networks, depending on the community. Some were formal, but the majority were informal. Of the forty-six applicants, 19 had formal networks in place. The majority of these formal networks were in Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) states. All of the EACH/RPCH states (California, Colorado, Kansas, Nebraska, New York, South Dakota, West Virginia) had a history of network development efforts. They described network development as fundamental to the rural health system. EACH/RPCH states, like Kansas, were more likely to encourage the creation of complex vertical networks than other states, which tended to focus on horizontal networks. Colorado has several large formal networks and refers to them as "businesses." Mississippi currently has one horizontal network of 11 smaller rural hospitals. However, the local project, The Robert Wood Johnson's Southern Rural Access Program, is requesting $300,000 to fund network development activities. Part of this funding will be used to transform the horizontal network to a vertically integrated network. South Dakota was ambitious in outlining its network objectives for Year 02. They propose to continue to develop and implement at least six rural health networks emphasizing practical computer Local and Wide Area Network (LAN/WAN).

State requirements for network development varied. Some states required all CAHs to belong to extensive networks, while other states required nothing beyond the minimum federal requirement of one network per state. Wisconsin focused on provider networks, which it defines as the existing transfer agreements between CAH facilities and tertiary inpatient care facilities. Nebraska requires every CAH to have a network agreement with a supporting hospital. Nebraska has seven networks that have at least three CAHs associated with them. Two in-state networks each have two CAHs, and there are also two networks that cross state lines. Nebraska is one of the few states that followed grant guidance to the letter in description of network formation and network activities.

Several states mirrored Kentucky's efforts and developed a survey instrument to identify the different network arrangements currently in existence. Most survey instruments produced some baseline data regarding current networks and a mechanism for assessing success or failure of past networks. Virginia's proposal shed light on the fact that there were few, if any, comprehensive rural health networks in the state.

Several states with strong urban networks in place were expanding them to include rural areas. Several states referenced political, image and/or staffing problems as barriers to network development. Some states were spurred into action by the requirements of the Flex Program and began assessing their current networks and/or assessing network needs. Only one state, Ohio, had no network development activities in Year 01; however, the plan in Year 02 is to hire a consultant to assist with network development. In some respect, it seems the Flex Program provided states with a framework for future "formal" network development. 

Budget Activity

Networks - Total Funds
	Amount Spent So Far in Year 01, as of 5/25/00	Amount Expected to Be Spent for the Full Fiscal Year 01	Projected Amount Proposed to be Spent in Year 02
Number of states	30	38	39
Total	$1,745,492	$2,488,601	$5,795,014
Per state mean	$85,146	$121,395	$289,751
Median	$17,850	$35,930	$106,000

Note: Not all states included budget details with dollar amounts States excluded from all columns are AR, CT, NM, NJ, NV, OR, PA, RI, UT. Funds include all resources utilized for the project, including those other than the requested Federal grant funds.

Common goals among states for Budget Year 02 were:

• Explore health system improvements such as telemedicine.

• Strengthen and integrate the EMS system.

• Continue to foster the development and implementation of rural health networks in CAH communities.

• Seek outside assistance for help with network development.

• Build on Year 01 activities such as workshops and educational seminars that focus on building networks.

• Provide technical assistance in the areas of coalition building, survey design and data analysis, community needs assessment, asset mapping and strategic planning.

• Conduct assessments to determine the type of network, hospitals needs and barriers to networks.

Most states recognized the importance of networks but were unable to focus their efforts in Year 01 due to the concentration of resources on CAH designation and state plan development or lack of funds. EACH/RPCH states were the exception.

States able to devote resources to network development are assisting hospitals in building networks. New York promotes a comprehensive approach to rural networks and created the Rural Health Network Development Program (RHNDP) to support such activities. The RHNDP along with the Office of Rural Health work with 34 rural health networks to discuss the value of networks to CAHs. Utah established the University of Utah Telemedicine Outreach Program to coordinate with network coalitions to advance telehealth in rural areas. Kansas grant funds are being used for the development of an Integrated Network Development Plan (INDP). Each network is encouraged to develop a plan that defines the direction, priorities, and operations of the network.

Improvement of EMS Services

In this section, applicants were asked to discuss what activities they plan to establish or expand to improve and integrate rural emergency medical services, especially where CAH designation will occur. Applicants were also asked to identify the CAH service areas in which EMS systems will be integrated as part of the network development efforts.

Several states made it a requirement to enter a transport agreement with an area EMS before being certified as a CAH. Almost all states encouraged and provided support to enhance and develop the EMS systems serving CAH networks. Some states were not able to support network or EMS development because of a lack of funding. For example, Kentucky received zero dollars in Year 01 for EMS improvement. However, there have been several meetings to discuss EMS needs in Year 02 as well as future EMS challenges as more hospitals convert to CAH. Some of these challenges are an increase in the number of interfacility transfers and potentially longer transportation to distant hospital emergency departments. Eastern Kentucky University and Western Kentucky University have joined forces to address EMS training shortages and assess community needs. 

Missouri dedicated a page of its grant application to the importance of EMS to rural health and describing the EMS deficiencies in the state; however, no efforts had been made to improve EMS in Year 01 (no reason was given). Missouri does plan in Year 02 to improve and integrate rural EMS into CAHs and their rural network. Michigan had to postpone EMS-related activities in Year 01 because the necessary funds were not provided. However, four work groups were formed around transportation issues. This was funded by the state's Rural Health Initiative.

Nebraska has undertaken three studies: 1) identify key factors that have caused adult test anxiety, a factor in certifying more EMS volunteers; 2) identify key factors that affect recruitment and retention of EMS volunteers; and, 3) implement quality assurance and quality improvement plans and policies that rural hospitals and local ambulance services currently have in place.

Common state challenges were turf battles, lack of training and adequate funding, and retention and recruitment. Many states have difficulty in training and upgrading the existing skill levels of current or potential employees to meet local needs. Recruitment and retention of emergency medical technicians (EMTs) continue to plague most states due to low wages, low ambulance run volume and lack of advancement opportunities. In addition, states face the challenge of the lack of quality and appropriate continuing education for paramedics, EMT-basics, and EMT-first responders.

States used similar strategies to address these challenges. Most focused on training programs, continuing education development, cross-training, and distance learning programs. Connecticut plans to encourage and assist an innovative program in high schools to offer EMS training as part of their elective curricula.

Several states planned to assess EMS needs and conduct a survey of CAH service areas before making any plans. In addition, states talked about improving collaboration with EMS systems, rural hospitals, and existing EMS coalitions or committees. In several states, grant funds from Year 01 were used to improve EMS integration in CAH networks and for training and upgrading of emergency medical personnel and equipment. Common themes among the state applications included continuing education and funding enhanced EMT training in rural communities as well as enhancing the various relationships between EMS staff and medical providers.

Iowa and Massachusetts planned to implement pilot programs in Year 02. Iowa said it would use a portion of grant funds for five EMT-B certification scholarships. Massachusetts plans to implement a program to support targeted, community-level EMS planning in four rural communities with potential CAHs.

The majority of states were focusing on at least one, if not several of these activities:

• Development/modification of referral and transfer protocols.

• Training of emergency medical personnel.

• Upgrading EMS equipment and providing computers to small ambulance services.

• Recruitment and retention of EMS personnel.

• Improving communication between the hospital and EMS providers.

• Developing assessment tools to determine EMS needs in CAH service areas.

• Developing EMS information system to collect and analyze data on EMS response time.

Budget Activity

EMS - Total Funds
	Amount Spent So Far in Year 01, as of 5/25/00	Amount Expected to Be Spent for the Full Fiscal Year 01	Projected Amount Proposed to be Spent in Year 02
Number of states	28	32	38
Total	$863,343	$1,367,492	$3,735,793
Per state mean	$22,137	$35,064	$100,967
Median	$11,121	$17,815	$84,300

Note: Not all states included budget details with dollar amounts. States excluded from all three columns are AR, CT, DE, NJ, NM, NV, OR, PA, RI, UT. Funds include all resources utilized for the project, including those other than the requested Federal grant funds.

Common goals among states for Budget Year 02 were:

• Conduct Needs Assessments.

• Develop hospital and EMS partnerships.

• Enhance and integrate EMS.

• Provide continuing education and training.

• Provide technical assistance for the development of EMS and trauma systems.

Quality of Care

In this section, applicants were asked to describe activities associated with ensuring quality of care delivered in critical access hospitals and activities related to the implementation of these activities. In addition, applicants were to describe what certification or accreditation procedures were being implemented and stakeholder and community participation.

There was no common theme in this section among states. In most of the applications, this section provided the least amount of information compared to other goal sections. The majority of applicants chose to focus on credentialing, certifications and standards that are currently in place. A few states provided comprehensive descriptions of their quality of care goals, objectives, and the plans to leverage existing quality of care programs. Three states had made no progress in this area due to lack of funding, time and/or resources: 1) South Dakota because of limited staff resources; 2) Mississippi because there were no CAHs at the time of application writing; and, 3) Wyoming - no reason was given.

In some state applications, there was no indication of a requirement for credentialing and quality assurance with at least one hospital that is a member of the network to which the CAH belongs. Other states had state-based quality programs or quality of care initiatives. In most states, CAHs are either Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited or are strongly urged to seek accreditation. 

An example of a state-based quality program is Arkansas, where a quality initiative is comprised of separate components: the perception of quality, delivery of care indicators, and the development of the relationship between CAHs and their network affiliate hospitals. Further development and refinement of this program is due to the efforts of the Arkansas Center for Health Improvement (ACHI). Grant monies fund the contribution of the quality manager of ACHI. 

In several states, it seemed the Flex Program acted as springboard for states to review and rethink current quality of care procedures and consider structural changes within the hospital. These states created quality assurance task forces and began assessing and reviewing quality of care needs and requirements in their state. Several states were encouraging CAHs to have a memorandum agreement with a peer review organization (PRO). All states appeared to be using outside assistance to help with this portion of the Flex Program. 

Of course, some states already had quality improvement programs in place. In Tennessee, CAHs are required to participate in the established PRO Health Care Quality Improvement Program. In Kansas CAHs participate in the annual Kansas Hospital Association Patient Satisfaction Project, an annual mail survey that focuses on patient satisfaction with inpatient, outpatient, and emergency services. In Year 02, the goal is to shift the focus of quality assurance (QA) and credential activities from the facility level to the network level involving PRO more directly in assessing quality and making policy recommendations. This was the only state with this type of objective.

Several states were focusing on telehealth networks linking CAHs in the state and on developing telecommunication technology and training hospital staff.

Budget Activity

Quality Assurance - Total State Funds
	Amount Spent So Far in Year 01, as of 5/25/00	Amount Expected to Be Spent for the Full Fiscal Year 01	Projected Amount Proposed to be Spent in Year 02
Number of states	23	27	35
Total	$508,039	$1,055,366	$2,190,067
Per state mean	$12,701	$26,384	$57,633
Median	$4,293	$9,669	$37,500

Note: Not all states included budget details with dollar amounts. States excluded from all three columns are AR, CT, DE, FL, NJ, NM, NV, OR, PA, RI, SD, UT, WY. Funds include all resources utilized for the project, including those other than the requested Federal grant funds.

States that spent zero dollars on quality improvement in Year 01 yet were requesting grant funding for Year 02 were: 

• California: No activities were described in Year 01. In Year 02, the Rural Health Office planned to participate in the Patients' Evaluation of Performance in California. A quality management tool administered by the California Institute for Health Systems.

• Louisiana: No activities were started in Year 01. In Year 02, plans were to reassign Quality Assurance Task Force responsibilities, implement a quality assurance survey tool and compose agreements for credentialing and quality assurance.

• Maine: no funding was made available in Year 01. In Year 02, the Rural Health Unit was to work with the Quality Assurance Division of the Bureau of Medical Services to assess CAH hospitals quality needs.

• Maryland: No activities were described in Year 01. The state office of rural health planned to work with the Flex Steering Committee and the PRO to assess quality improvement status at the participating CAH.

• Mississippi: No activities occurred in Year 01 because there were no CAH facilities yet. In Year 02, the state office of rural health was to work with the state PRO to design education programs for CAH hospital utilization review and medical staff to address any changes necessary to assure facility compliance with federal regulations.

• North Carolina: There were zero dollars spent in Year 01; however, some Year 01 activities included: credentialing and quality improvement activities were integrated into the provider network, and a partnership between CAH and the community ACCESS II and III programs. Year 02 activities included: funding "best practices" guidelines, holding workshops and education programs, developing quality improvement models and tools packages.

• Vermont: The absence of a full-time project administrator prevented any activities in Year 01. In Year 02, The Vermont Program for Quality in Health Care was to develop specific quality measures for use in Vermont's rural communities.

Because very little was done in this area in Year 01, several states are planning to increase or begin hospital quality of care activities in Year 02. However, there were some common themes among states for Budget Year 02:

• Develop quality assurance and protocols for CAHs and other healthcare facilities.

• Ensure that credentialing protocols are in place.

• Continue identifying quality assurance concerns.

• Sponsor workshops for hospitals emphasizing quality assurance, credentialing and communication.

Budget Activity Summary for Five Goals of Rural Hospital Flexibility Grant

	Per State
	Total	Mean	Median
1.  RURAL HEALTH PLANS
Amount spent so far in Year 01, as of 5/25/00	$925,811	$23,739	$8,419
Amount expected to be spent for the full fiscal Yr 01	$1,186,627	$31,227	$13,373
Projected amount proposed to be spent in Yr 02	$1,331,447	$35,985	$18,764
2.  DESIGNATION
Amount spent so far in Year 01, as of 5/25/00	$4,813,891	$120,347	$111,689
Amount expected to be spent for the full fiscal Yr 01	$5,604,975	$140,124	$135,250
Projected amount proposed to be spent in Yr 02	$7,119,091	$182,541	$135,347
3.  NETWORKS
Amount spent so far in Year 01, as of 5/25/00	$1,745,492	$85,146	$17,850
Amount expected to be spent for the full fiscal Yr 01	$2,488,601	$121,395	$35,930
Projected amount proposed to be spent in Yr 02	$5,795,014	$289,751	$106,000
4.  EMS
Amount spent so far in Year 01, as of 5/25/00	$863,343	$22,137	$11,121
Amount expected to be spent for the full fiscal Yr 01	$1,367,492	$35,064	$17,815
Projected amount proposed to be spent in Yr 02	$3,735,793	$100,967	$84,300
5.  QUALITY ASSURANCE
Amount spent so far in Year 01, as of 5/25/00	$508,039	$12,701	$4,293
Amount expected to be spent for the full fiscal Yr 01	$1,055,366	$26,384	$9,669
Projected amount proposed to be spent in Yr 02	$2,190,067	$57,633	$37,500

Note: Not all states included budget details with dollar amounts. Funds include all resources utilized for the project including those other than the requested Federal grant funds.

Back to Table of Contents

Footnotes

¹ There was also a $200,000 baseline grant issued less than one year before Year 01, which went to each eligible state grantee.

² Source: http://www.doh.wa.gov/hsqa/ocrh/.

RHFP Home
RHFP Information | RHFP Tracking Project | RHFP Publications | RHFP Contacts
Search | RUPRI

Copyright © 1999, Rural Policy Research Institute
DMCA and other copyright information.
Last updated 20 October 2008 03:44:20 PM -0500
URL: http://www.rupri.org/rhfp-track/year2/appendixb.html