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Rural Hospital Flexibility Program Tracking Project

Appendix D1
State Level Site Visit Protocol and Interview Guide 
(Final Version)

INTRODUCTION

In this second round of site visits, we will be using this state-level site visit protocol instrument to guide interviews with the additional eight states. As in the first round, we will be meeting with the lead agencies and organizations (e.g. State Office of Rural Health and Hospital Association), other agencies of state government (e.g. Medicaid, Hospital Licensure and Certification), and relevant stakeholders (e.g. Rural Health Association). Because this second round of site visits is occuring two years into the RHFP, some of the questions from the original instrument have been revised to reflect the evolution of the state's Flex Program that is likely to have occurred. We are seeking information on the following topics: 

1. The history of state policy and planning on rural health and hospital issues;

2. The state's goals in the Rural Hospital Flexibility Program (RHFP);

3. The state's plans and priorities for using RHFP grant funds;

4. The role of the state and other key stakeholders in the planning and implementation of the RHFP;

5. RHFP implementation successes and problems, including the capacities of key players, federal-state-local policy and program coordination, the nature and degree of stakeholder involvement in the planning process and the degree of stakeholder agreement with the goals of the state's RHFP, regulatory issues, and local implementation; and 

6. Key lessons learned.

I. HISTORY OF STATE POLICY AND PLANNING ON RURAL HEALTH AND HOSPITAL ISSUES 

This section of the protocol focuses on the extent and the nature of state-level planning and policy development prior to the passage and implementation of the RHFP. Some of the questions we want to address here are:

• How does the extent of prior rural health policy and planning activity in a state (either state government or in the state hospital association) affect the level, nature, and success of policy development and planning activity under the RHFP?

• What factors account for the degree of state-level policy development and planning on rural health issues? 

• To what extent is the RHFP consistent in purpose and approach with prior state-level policy development and planning efforts?

  • Goals

  • Stakeholder participants

  • Planning focus, priorities, and strategies

• What impact has the RHFP had on rural health/hospital policies and initiatives?

1.  We're interested in the history of rural health planning and policy initiatives in this state. Prior to the passage of the RHFP Act, how did this state address the problems of vulnerable rural hospitals and health systems?

• How have rural health systems and hospitals fared in this state? To what extent and how did you monitor the status of rural health systems and rural hospitals in this state?

• Prior to the RHFP, what programs or initiatives did this state have encouraging or supporting network development and collaborative arrangements between rural providers and between rural and urban providers (e.g., Were there any special programs providing resources or affording regulatory flexibility or did they take a more relaxed view on organizational relationships than might have been taken if the law and regs were exactly enforced?)

2.  Are there any specific individuals or organizations that have played a key role in planning or policy development around rural health issues in this state? How have they influenced the process?

3.  What outcomes have these individuals or groups been most likely to support (e.g. maintaining full hospital capacity in rural areas at all costs, mergers and consolidations, downsizings, closures)?

4.  To what extent and how has leadership on rural health issues generally and rural hospitals in particular changed over time? Governor's office? Legislature?

5.  How has the RHFP program planning and implementation process affected the visibility of rural health issues in this state? Can you provide some examples? 

II. THE STATE'S GOALS IN THE RURAL HOSPITAL FLEXIBILITY PROGRAM (RHFP)

How states develop and use health plans varies considerably. The focus of this section is on (1) the "planning orientation" and process of the state agencies responsible for the RHFP and the collaborating stakeholders and (2) the states' priorities for using the RHFP grant funds. 

• What is the scope of the state's rural health plan? 

• To what extent does the plan focus on "hospital conversions" versus "rural health infrastructure development" (e.g. network development, personnel recruitment and retention, community needs analysis, EMS)?

• How has the state used RHFP grant funds? To what extent have these been directed to sites and/or to enhancing state capacity? Where funds have been directed to sites, how essential have these funds been to the local hospitals and sites? How have the sites benefited in the case of grant funds used to build state capacity?

• How has the state's goals and spending priorities changed/evolved in the second year of the Flex Program? 

1. To what extent has the RHFP provided opportunities to meet your state's goals and priorities?

• Probe for focus on/orientation to RHFP as vehicle for hospital survival, rural health systems/network development, quality improvement, community economic development and/or other goals.

2. To what extent has there been agreement or conflict among key stakeholders over the priorities for this program? What are the issues that have precipitated conflict?

3. How has this conflict affected the planning for and implementation of the RHFP?

4. How well does the RHFP fit with this state's rural health policy and planning priorities?

• To what extent have you molded the RHFP to your needs and priorities? With what effects?

• To what extent has the RHFP changed your goals and priorities and with what effects? 

• How have the state's goals/spending priorities changed in Year 2? Why?

III. THE STATE'S RURAL HEALTH PLAN, RHFP PROPOSAL, AND PLANS FOR USING RHFP GRANT FUNDS.

The purposes of this and the following section are (1) to obtain information that will enable us to characterize the role(s) that states have played in the development and implementation of the RHFP, and (2) to assess the roles that key stakeholders, like the hospital association, have played in the planning and implementation of the RHFP.

• What roles have states played in facilitating the regulatory framework/process, providing grant funds to sites, providing technical assistance etc.? Which has been a priority and why?

• How has the state's rural health capacity affected the development and implementation of the RHFP?

• What roles have other stakeholders played?

• How do variations in state roles and capacity affect implementation and success of the program? 

1. Please describe the process by which your state's rural health plan and most recent RHFP proposal were developed. Who else/what other agencies participated in the development of the RHFP proposal? 

2. How has this changed over the two years of the Flex Program?

3. How useful was the plan and planning process in your state's development and implementation of the RHFP program? Why? What were your major priorities in developing the plan.

4. According to your grant application, grant funds were to be used in the following ways. (List activities.) What are the primary components of your RHFP in order of priority? 

5. Did you receive the full amount of funds requested in your state's RHFP proposal? If no, how have you modified your plans for the RHFP in light of your reduced funding? What specific activities have you cut?

6. Are any other funds being used to supplement the RHFP award? If so, what is the source and size of the supplement?

7. Have you made any other changes to the use of funds for reasons other than funding cuts? If so, what changes and why?

8. How are RHFP grant funds distributed within the state? Who decides how funds are awarded? How is the process working? What problems have you encountered?

9. What organizations have received RHFP grant funds? How much have they received and what have they done with the money?

10. What role have these funds played in the development, implementation, and on-goint management of the RHFP in your state?

IV. THE ROLE OF THE STATE AND OTHER KEY STAKEHOLDERS IN THE PLANNING AND IMPLEMENTATION OF THE RHFP

1. What role does this agency have in the planning, program development, and implementation of the RHFP? Please describe in detail.

2. Please describe the services, if any, your agency provides to hospitals contemplating CAH conversion. Do you provide technical assistance? If so, what type of assistance and how is it provided.

3. Who were the key stakeholders (organizations and individuals) involved in the early planning process for the RHFP and what roles did they play? Have new stakeholders entered the planning process as the Flex Program has evolved?

4. What role have/are state staff in other agencies such as health planning, hospital licensing, certificate of need, EMS and Medicaid playing in the development and implementation of the RHFP? 

5. How have state Executive and Legislative branch stakeholders facilitated or hindered planning and implementation efforts?

6. Are there any important stakeholders that did not participate in these planning processes or had limited involvement? Which groups? Why was their involvement limited? How did this affect the outcomes of the process?

7. How would you assess your state's capacity (e.g. $, personnel, technical knowledge) for administering the RHFP planning and implementation process? What problems and opportunities does the program present for your organization?

8. How are you staffing the RHFP program? What roles do your staff involved with the RHFP play? Have you used outside consultants during this process?

9. Have you added new staff, reallocated staff from other functions or locations, reorganized, provided staff training?

10. How has the RHFP program affected the capacity of your agency to deal with the rural health problems of this state? 

11. How has it affected other state agencies (e.g. health planning, hospital licensing, certificate of need, EMS and Medicaid)? 

12. What additional resources, if any, are needed to improve your state's capacity to administer the planning and implementation process? 

13. To what extent and in what ways have you worked with or learned from the experiences of other states in organizing or implementing the RHFP in your state?

14. For EACH/PCH states: How has your experience with the EACH/PCH program affected your approach to the development and implementation of the RHFP?

V. RHFP IMPLEMENTATION AND MANAGEMENT

Here and in the next section we are seeking information about program development and implementation approaches, the successes and problems that states have faced, and the degree of generalizability among states. 

• How common or idiosyncratic are the development and implementation barriers and problems that states have faced?

• What factors have contributed to these barriers/problems?

• What are the most successful features of the states' development and/or implementation approaches/strategies? To what extent is it generalizable?

• What accounts for this success? 

• What, if any, management/oversight issues have arisen as the Flex Program has evolved?

1.  What criteria have you used in identifying candidate hospitals for the RHFP?

2.  How would you asses the capacity of your eligible hospitals (or their parent companies) to perform the tasks necessary to prepare for conversion to CAH status? What technical assistance resources are they using and how have they accessed those services?

3.  Has the implementation of the RHFP proceeded on schedule-or faster or slower than you expected? Why? 

4.  Please describe to us how you have worked with each of the hospitals that have considered or have converted? 

5.  Are you encouraging other eligible hospitals to apply for CAH status? How many? Which ones? What strategies are you using? What is the resistance or reluctance?

6.  What have been the most significant problems you have in this state in planning and implementing the RHFP and how have they affected the program? 

• If needed, prompt with any of the following issues or problems as examples:

  • Regulatory and legislative changes;

  • Education of and coordination with fiscal intermediaries;

  • EMS improvements

  • Quality assurance/improvement

  • Network building

  • Provider recruitment/retention

  • Exceptions to the 96-hour average length of stay limit;

  • Inadequate state, hospital, or community commitment to program goals;

  • Lack of technical assistance to hospitals;

  • Difficulties in getting hospitals or communities organized; 

  • Development and conduct of community needs assessments and community education;

  • Difficulty in identifying or recruiting network partners;

  • Difficulty defining roles and responsibilities of network partners; 

  • Development of guidance and/or requirements for credentialing and quality assurance for rural hospitals/networks;

  • Development of EMS services;

  • Medicare reimbursement;

  • Medicaid reimbursement;

  • Commercial and managed care reimbursement;

  • Coordination with HCFA regional office;

  • Coordination with Medicare Fiscal Intermediary; and/or

  • Other (please explain)

7.  Are there other management or program oversight problems you have faces in this state? How have you dealt with those?

8.  What effects have the changing requirements of the Flex/CAH program and Medicare payment rules made in the Balanced Budget Relief Act (BBRA) and in the Benefits Improvement and Protection Act (BIPA) affected the development and implementation of the program in this state? How have you addressed these problems? With what success?

9.  How are you monitoring the performance of designated CAH's over time? 

VI. LESSONS LEARNED

1.  What are the most successful strategies or features of your Flex Program? (Provide examples)

• What accounts for this success?

2.  What do you consider the least successful features of your program?

• Why have these features not been successful?

3.  What impact, if any, has the RHFP had on your state's other rural development and rural health programs and priority initiatives?

4.  What are the most important lessons of your experience to date with the RHFP for other states and hospitals?

VII. RHFP EVALUATION PLANS

The questions in this section seek information on the states' plans for evaluating the RHFP, what they hope to learn from that evaluation, and the approaches and measures they propose to use.

• How are states approaching their evaluations of the RHFP?

• What approaches are they using?

• What are they most concerned with learning from these evaluations? 

1.  Is your state evaluating the RHFP program? If so, what do you/they hope to learn from this evaluation? 

VIII. FUTURE PLANS

1.  What are your future plans and priorities for the RHFP in this state? Are there any related initiatives that you are pursuing or plan to pursue in the future? 

2.  To what extent does the RHFP meet your state's needs? How could the legislation or its implementation be changed to better suit your state's needs?

 

Module 2: EMS Interview Questions for SORH Representative

I. IMPRESSIONS REGARDING RURAL EMS IN THE STATE

1.  In general, how do you think the EMS system is working in rural areas of your state? What are the major strengths? The major shortcomings?

II. INVOLVEMENT OF STATE EMS BUREAU IN RHFP PROCESS

1.  How involved was the State EMS Bureau in development of EMS initiatives under the RHFP? In the preparation of the state's RHFP grant applications (year 1, year 2)? Was this a new collaboration with SORH and other state agencies?

III. EMS INITIATIVES UNDER THE RHFP -- YEAR 1

1.  What EMS activities did your state undertake in the first year of the RHFP (Fall of 1999-Summer 2000)? (Could also include activities carried out with the original planning grant funds. We are most interested in what they did, which may differ from what they proposed to do.)

2.  What is the status of these activities? Are they completed? On schedule? If not going as hoped, what types of problems are you running into? What remains to be done?

3.  Do you have any evidence on the outcomes of these activities?

4.  How would you characterize the priority given to EMS activities during the first grant year (relative to other Year 1 program activities such as CAH designation)?

5.  Had the state planned to conduct any other EMS activities during the first program year that were not undertaken? Why were these activities not undertaken (e.g., funding cuts, implementation problems, other priorities)? Are there plans to conduct these activities in the future?

IV. EMS INITIATIVES UNDER THE RHFP -- YEAR 2

1.  According to your most recent grant application (submitted to ORHP in May 2000), you proposed the following EMS activities in the second year of the RHFP (Fall 2000 through Summer 2001):

Project HOPE can provide this information to each site visit team prior to the visit

Confirm that this information is accurate, clarify as needed.

2.  Have you made any changes to these planned activities? If so, what has changed (activity dropped, scope changed, budget changed)? Why was this change made?

3.  Why were these activities selected over alternative approaches that might have been used to address these challenges?

4.  How would you characterize the priority given to EMS activities during the current grant year

- relative to other program activities in the current year? 
- relative to the EMS emphasis last year?

5.  FOR STATES USING GRANTS TO CAHs/EMS ENTITIES AS A WAY OF DEFINING AND CARRYING OUT EMS ACTIVITIES: 

- What is the status of this grant process? 
- What types of EMS improvement activities were proposed? 
- What activities were funded? 
- How were the winning grants selected? 

6.  For each EMS activity being undertaken in Year 2, what is the schedule for implementation? How is implementation proceeding relative to expectations? If not on schedule, what obstacles have impeded progress? What factors, if any, have facilitated implementation?

7.  Do you have any evidence yet regarding the outcome of these activities?

V. CAH CONVERSIONS AND EMS

1.  What challenges, if any, do the CAH conversions pose for the EMS systems in the local community?

2.  What opportunities do these conversions (and the RHFP, more generally) present for strengthening EMS systems in the local community? For making EMS part of the larger rural health network?

3.  How were EMS concerns considered during the CAH application process (e.g. EMS consultant was part of the pre-conversion assessment teams, state required EMS providers to be consulted in conversion decision)?

VI. KEY LESSONS AND CLOSING

1.  Have any major successes been achieved for rural EMS during the first two years of the RHFP? Any major disappointments or setbacks?

2.  Are there any problems remaining with the state's rural EMS system that you think could be helped by (additional) RHFP funds? What (else) would you like to see happen as a way of improving the provision of EMS in rural areas of your state? Is the state planning to move in this direction in future years of the RHFP?

3.  Do you have any suggestions for ways to improve the RHFP so as to achieve additional improvements in rural EMS? (These might be suggestions to ORHP regarding national changes to the program, or for states and communities regarding the way the existing RHFP is being implemented.)

4.  Do you have any advice for EMS stakeholders in other states interested in making similar improvements to their rural EMS system?

5.  Our team is also going to visit CAH/community #1 and CAH/community #2 . 

- Is there anything we should know about the EMS situation in these communities, or about the ED situation in the CAHs? 

- IF STATE AWARDS GRANTS FOR EMS UNDER RHFP: Did either of these hospitals/communities receive RHFP grant money for EMS-related initiatives?

6.  IF NECESSARY: Could I please get your job title and a phone number in case other members of our team wish to contact you later for additional information?

Job title: ______________________________________
Phone: _______________________________________

7.  Is there anyone else that you think we should speak with to gather additional information on the EMS initiatives being undertaken in this state under the RHFP? (These contacts could include other state government officials, consultants, and contacts at the CAHs/communities to be visited. May wish to prompt for the name of a good contact at the state EMS Bureau.) 

Please get name, title, and phone number, plus try to indicate why this person is being suggested.

Name: _____________________________________________________________
Job title: ___________________________________________________________
Phone: ____________________________________________________________
Reason to contact: __________________________________________________

Name: _____________________________________________________________
Job title: ____________________________________________________________
Phone: _____________________________________________________________
Reason to contact: ___________________________________________________

1.  What role did/does this agency have in planning for the RHFP and in implementation?

2.  What other agencies are involved in CAH conversions? Other aspects of the RHFP? How do you work with them?

3.  Please describe the process by which your agency is involved with CAH conversions? Other aspects of the RHFP (e.g. post conversion monitoring of CAHs)?

4.  How long does it take to complete your agency's portion of the process?

5.  What are the major barriers or delays that can occur in the CAH conversion process? What sort of a delay do they create?

6.  How are you staffing for the work related to the CAH/RHFP program? Have you used outside consultants during this process? Have you added new staff, reallocated staff from other functions or locations, reorganized, provided staff training?

7.  Are additional resources needed to improve your state's capacity to administer the planning, implementation, and on-going management process? If so, what resources? 

8.  Have you worked with or learned from the experiences of other states in managing the RHFP in your state? How so?

9.  For EACH/PCH states: How has your experience with the EACH/PCH program affected your approach to the development and implementation of the RHFP?

10. Have you learned any lessons that will be valuable for other states in implementing their RHFP/CAH programs?

11. How has the program affected the capacity of your agency to deal with the rural health problems of this state?

1.  What role did this organization have in planning for the RHFP and in its implementation? Has this role changed over time? If so, how?

2.  To what extent are the goals of the RHFP program in this state consistent with those of this organization/agency? 

3.  Are additional resources needed to improve your state's capacity to administer the planning and implementation process? If so, what resources?

4.  How has the program affected the capacity of your organization to deal with the rural health problems of this state?

5.  How would you assess the success of your state's RHFP/CAH program?

APPENDIX

The following is a list of potential interviewees for the state-level site visits. We assume that the Offices of Rural Health will be the lead agency in most states. The lead agency will be identified from each state's grant application. We will identify a list of relevant stakeholders during preliminary phone conversations with the lead agency prior to the site visit.

Organization	Relevant Contacts
Office of Rural Health	Director Staff member assigned to CAH/RHFP issues
State Health Planning	Planning Director Staff member assigned to CAH/RHFP issues
Certificate of Need Office	Staff member assigned to CAH/RHFP issues
Department of Health	Director Planning staff assigned to rural hospital issues Staff member assigned to hospital reimbursement issues
Medicaid Agency	Staff member assigned hospital reimbursement issues and/or CAH program
Office of Primary Care	Director Staff member assigned to rural recruitment issues
Governor's Office	Staff member assigned to rural health issues
State Legislature Staff	Staff member assigned to rural health issues
Medicare Fiscal Intermediary	Staff member assigned to hospital reimbursement issues and/or CAH program
PRO	Director Staff member assigned to rural hospital issues and/or CAH issues
Hospital Association	Staff member assigned to CAH and/or rural hospital issues
Rural Health Association	Director
Rural Development Commission	Staff member assigned to health issues
Agriculture/Cooperative Extension Service	Staff member assigned to health issues

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