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Rural Hospital Flexibility Program Tracking Project

Chapter 3D
Local Networking Strategies Used by Critical Access Hospitals

John A. Gale, M.S.
University of Southern Maine

Overview

As community institutions, critical access hospitals (CAHs) must be responsive to the needs of their communities and the populations located within them. In recognition of this fact, the Rural Hospital Flexibility Program (Flex Program) contains provisions to encourage CAHs to engage in networking activities as a way of identifying and addressing local health care infrastructure problems and needs. This chapter will focus on the local networking activities in which CAHs engage and the impact of those efforts on the hospital and the local health care infrastructure.

Local community networking initiatives are often overlooked in discussions of CAH networking efforts as the focus is generally on the linkages between CAHs and larger hospitals or health care systems. Despite this tendency to underestimate the importance of local community networking activities, they can be a critical element of a CAH's efforts to connect with its community. Effective local linkages can help to develop the trust that results in the expanded use of the CAH's services and to cultivate greater political and financial support within the community. These networks can also serve as a source of information on the scope of services needed and desired by the community and its populations. In this way, successful local networking efforts can support the development of the local health care infrastructure by mobilizing the efforts of multiple community providers, and can serve to better integrate local services by cultivating relationships between these providers.

These local community networking efforts can include, but are not limited to program or service enhancement initiatives with public health agencies, health departments, school systems, school-based clinics, physicians, rural health clinics, community health centers, dental clinics, mental health service organizations, and/or alternative health care providers. The exact mix depends on the composition of providers and agencies present in the community, their traditional roles, and the level of rapport and trust they share.

Local networking initiatives have much in common with the broader set of community development activities discussed in Chapter 5. The major differences are that local networks are primarily composed of health care providers and are focused specifically on maximizing the functioning of available health resources and building new services as dictated by community needs. Community development initiatives, in comparison, are likely to include a broader range of stakeholders (e.g., business and community leaders, consumers, and local government officials, as well as health care providers) and activities, including a broader array of public health functions. We would expect to see local networks engaged in identifying and developing new services that are needed, identifying and reaching out to underserved populations, and addressing access barriers such as transportation, geography, or language.

We did not expect to find a great deal of local networking activity despite the expectations of some federal and state officials that CAHs will engage in this type of activity under the Flex Program. Our expectations were based on three factors which were confirmed by our observations during our Year 01 site visits. First, incentives for local networking have not been especially strong nor clear except in states like North Carolina or Michigan. Second, many hospital administrators and boards still define their hospitals by their inpatient activities. Finally, issues of short-term financial survival and/or the conversion process tend to occupy the attention of the administrators of struggling institutions. We did, however, find interesting examples in selected states such as Michigan, New Mexico, North Carolina, and West Virginia.

In an effort to better understand the nature of local networking efforts, the barriers to undertaking local networking initiatives at both the state and hospital levels, and the benefits both to CAHs and their communities, we have focused on this issue as a major component of our Year 02 study. We explored the following questions: 

1. To what extent are CAHs engaged in local networking?

2. What local providers and agencies are participating in local networks? 

3. To what extent are these local networks engaged in efforts to assess and address community needs?

4. What other activities are these local networks engaged in?

5. How are CAHs benefiting from participation in these efforts?

6. To what extent have these local networks strengthened local health care infrastructures?

In an effort to answer these questions, we drew on data collected from our telephone survey of 217 CAHs along with interviews with administrators, staff, and community representatives from 40 CAHs conducted during Years 01 and 02 and follow-up interviews with informants from the 24 CAHs visited in Year 01.

Survey of CAH Administrators

In the winter of 2000, the University of Minnesota completed telephone surveys of the administrators of 217 of the 239 hospitals that had been designated as Critical Access Hospitals as of September 1, 2000. The survey asked a series of questions about local networking including the types of networking activities taking place, the number of meetings between the CAH and local providers, and the degree to which CAHs are working with various players to determine community needs. Findings include:

• Most networking efforts are of the inter-community type, between CAHs and their affiliate hospitals (see Chapter 3C).

• Relatively little formal networking is taking place between CAHs and local providers.

• When local networking does occur, it is generally focused on public health or social support activities and efforts to identify the health care needs of the community.

Administrators were asked "how often do you meet with representatives of local public health, mental health, emergency medical service (EMS), and/or other similar community-based health care providers that were not formally affiliated with the hospital prior to becoming a CAH?" About a third reported meeting monthly or more often, another third met quarterly, and the last third met rarely if at all (Table 1). Although more than two-thirds of the responding administrators reported meeting with local providers on a quarterly or more frequent basis before conversion, the design of our survey did not allow respondents to indicate either the format or content of those meetings. 

Table 1.  Frequency of Meetings with Local Community Providers Before Conversion

Source: 2000 Survey of CAH Administrators.

As a follow up to this question, the respondents were asked if there had been any change in the level of community provider contacts since conversion to a CAH. Seventy five percent reported that the level of contact with community providers remained about the same. In comparison, 21 percent reported more contact and 4 percent reported less contact since conversion.

The administrators were also asked to identify the extent to which they worked with various types of providers in any planning or assessment efforts to identify the health care needs of their local community. The result are summarized in Table 2. Forty three percent reported working with their affiliate hospitals to identify community needs. The strategies used by CAHs and their affiliate hospitals to identify local health care needs included: 1) combined community needs assessments; 2) surveys, focus groups, and other data collection efforts; 3) strategic planning initiatives; 4) specialty care development; and 5) local and regional networking.

Nineteen percent worked with other health care providers with whom the CAH has long-term agreements or affiliations to identify community health care needs. The strategies employed under these networking arrangements included: 1) performing community needs assessments; 2) engaging in joint ventures/service development; 3) networking arrangements for sharing and analyzing data; 4) participating in consortiums or task forces; and 5) linking with local agencies and health departments.

Finally, 39 percent reported working with local providers with which the CAH did not have long-term agreements or affiliations to identify community needs. The strategies included: 1) participating in consortiums or task forces composed of community agencies; 2) conducting community needs assessments; 3) collecting, sharing, and analyzing data; and 4) the internal identification needs and/or problems. The responses to these questions are not mutually exclusive and some CAHs work with more than one category of providers to identify local health care needs.

Table 2.  CAH Network Partners in Identifying Local Health Care Needs

Source: 2000 Survey of CAH Administrators.

In an effort to determine the frequency of local community networking activities and the extent of the activities that occur under these networking arrangements, administrators were asked about a wide range of potential collaborative activities as well as the type of entities with which they collaborated around each activity. Table 3 summarizes their responses about the extent to which hospitals participated in these types of collaborative activities prior to conversion to a CAH.

Table 3.  Collaborative Activities by Type of Collaborative Partner

Source: 2000 Survey of CAH Administrators.

As can be seen from this table, the majority of collaborative efforts undertaken by CAHs involved their affiliate hospital and other providers with whom the CAH had formal affiliation agreements prior to conversion. The two service lines in which a significant amount of local networking took place prior to conversion were public health and social support activities. Of the 57 CAHs whose administrators indicated that they are collaborating around public health services, 68 percent were working with local, non-affiliated providers. Of the CAHs that engage in collaborative social support activities such as long-term care, case management, and mental health, 23 percent reported that they were networking with local non-affiliated providers.

Administrators were also asked if any affiliated or non-affiliated health care providers had made a significant contribution to identified changes in scope of services since conversion to a CAH. Only 5 CAHs out of 217 (slightly more than 2%) indicated that either kind of partner had made a significant contribution to the CAH's changes in scope of services. The providers identified included two hospitals, two specialty clinics, and a program offering obstetric (OB) nurse training. Of these five CAHs, only two indicated that a non-affiliated local provider had contributed to the hospital's scope of services changes. In contrast, 24 percent reported that their affiliate hospital played a major role in accomplishing their reported scope of service changes (see Chapter 3B).

Finally, administrators were asked to identify the networking roles related to quality assurance and quality improvement initiatives. Table 4 summarizes their responses.

Table 4.  Organizations Playing a Key Role in QA/QI Capacity Since Conversion to a CAH*

Source: 2000 Survey of CAH Administrators.
* These figures exceed 100 percent as the survey allowed for multiple responses to this question.

Not surprisingly, 58 percent of the respondents identified their affiliate hospitals as playing a key role in the improvement or refinement of their quality assurance (QA) and/or quality improvement (QI) capacity since conversion to a CAH. Ten percent named tertiary medical centers as important participants in the process. A similar number worked with a wide variety of organizations such as network and system partners, state hospital associations, management companies, EMS units, and other clinical providers around quality initiatives. Local community organizations including local providers (11%), public agencies such as the Departments of Health or Social Services (13%), and clinics/health centers (7%) were identified as participants in QA/QI activities. Of those CAHs that indicated that more than one organization played a key role, 69 percent named their affiliate hospitals as playing the most important networking role in improvements to their QA/QI initiatives (Table 5). Other local providers and clinics/health centers were mentioned as the most important network partners by only three percent and two percent of the respondents respectively (see Chapter 3F).

Table 5. Most Important Networking Partners in QA/QI Improvements

Source: 2000 Survey of CAH Administrators.

Site Visits

Members of the Tracking Team have visited twenty states and forty critical access hospitals in the first two years of the Tracking Project. During the second year of the Tracking Project, the team incorporated questions on local networking initiatives into the site visit protocols in order to expand on the data obtained through the telephone survey of CAH administrators and to understand how these efforts may be implemented at the hospital level. Similar questions were posed to the administrators of the CAHs visited in Year 01 during follow-up interviews conducted during the spring of 2001. Findings from the site visits include:

• Despite interesting examples of local networking in some states, CAHs generally have not been actively involved with local community agencies/providers in efforts to address community health needs and problems.

• The local networking efforts described by administrators focus on process indicators (e.g., meetings with local providers and collaboration on needs assessments) rather than outcomes and results (e.g., the development of new services, increase in patients referrals, etc.).

• Local networking efforts typically include local health departments and/or community service agencies.

While we did not see a consistent pattern of local networking activity across the states we visited, there are states and CAHs that have undertaken promising initiatives with the potential to stimulate community-level health system change and development. These initiatives provide examples of the value of local networking and can serve to stimulate the thinking of other CAHs in the development of their own local networking plans, and that of state policy makers as they seek to encourage CAHs to become more involved in their communities.

State-Level Initiatives

A number of states, including Idaho, Kansas, Michigan, North Carolina, North Dakota, Oregon, Tennessee, and West Virginia, strongly encourage CAHs to work with local agencies and providers to address community health needs under the Flex Program. Most typically, CAHs are expected to conduct community needs assessments in conjunction with local agencies and providers or participate as members of local coalitions of providers and agencies.

Oregon and Tennessee strongly emphasized their support for local networking initiatives in their interviews with the Tracking Team. Despite this fact, there was little local networking activity in the CAH communities that we visited. Oregon has created a program known as CHIP which stands for Community Health Improvement Partnerships. The goal of CHIP is to create local community health networks of up to thirty members representing both direct health resources as well as community, social, and economic agencies. Oregon has hired a nationally recognized expert in the field of rural community development to assist communities in developing their health care delivery systems. Flex Program grant dollars have been committed to the development of these networks in CAH and potential CAH communities. Despite the availability of grant dollars to support these initiatives, CHIP was not active in either of the two communities/CAHs visited.

Tennessee supports a series of regional Community Health Councils (CHCs) which are formal (state-staffed) organizations that engage in an intense community needs assessment process called Community Diagnosis. CHCs evolved from relatively informal grass-roots organizations. All 95 Tennessee counties have engaged in the Community Diagnosis process. The Tennessee Hospital Association, which administers the Flex Program, coordinates with CHC to provide the most current and relevant health data possible to inform the CAH decision making process. Both hospitals we visited described close relationships with the CHCs in their regions. However, little actual local networking appeared to be taking place.

Kansas's Office of Local and Rural Health is attempting to shift the focus of its rural health networks to more population-based activities. In this way, it hopes to target populations that fall through the cracks of the service system and provide a structure for local providers to work together. Kansas has been struggling with this issue as the majority of CAH/network projects have not been using the community-focused strategies described in the state health plan. Representatives from the state office of rural health described the difficulty of shifting the traditional horizontal hospital networks to community-based networks. They explained that horizontal networks are not structured to make these types of transitions naturally. It is their hope that they will be able to facilitate the transition by separating community development activities from network development activities in a way that makes it more attractive for all interested parties, and allows the participants to focus on specific outcomes of networking rather than the relationships themselves.

Idaho has been working with three communities to pilot a network enhancement project. The communities of St. Marie's, American Falls, and Weiser are initiating network development beyond the common hospital-to-hospital model and will include community health centers, public health districts, rural health clinics, and possibly the local justice and/or education systems. It will be a test to see if the state can effectively enhance system integration at the local level through the use of grants to encourage broader participation.

Staff from the New Mexico Office of Rural Health stated that local community networking is an important priority and that there is an urgent need to integrate private clinics, public health, EMS, community health centers, and mental health providers. Nonetheless, agencies in one community we visited have been engaged in strong, long-standing rivalries with each other. State offices that commit to helping communities resolve these conflicts face a daunting task, and need resources and time to have an impact. Few state offices are, at this point, equipped to work on these issues.

Michigan encourages local networking by funding the development of Multi-Purpose Collaborative Bodies (MPCBs) throughout the state. CAHs are encouraged to actively participate in these groups. MPCBs are community-based groups composed of a broad array of service providers and agencies that meet regularly to discuss local coordination and service issues. The state has also broadened its definition of networking in the second year of the Flex Program to include a variety of community-based health care providers and health care related organizations. One official from the Michigan Center for Rural Health conceptualizes these networks as a series of concentric circles with the hospital in the center, physicians and nurses in the next ring, and agencies such as public health and the United Way in the outer ring. Despite the state's emphasis on this concept, they admitted that it is catching on more slowly than expected and that most CAH networking efforts have occurred between hospitals.

The North Carolina Office of Rural Health also emphasizes linkages between local providers and CAHs. As part of the conversion process, CAHs must commit to working with local providers (including public health), supporting the continuation of necessary community services, and providing services to vulnerable populations. Staff from the state office of rural health estimate that 60 to 70 percent of the agendas for local networking efforts developed by CAHs are determined by the needs of the communities in which they are located. The remainder of their agendas are determined by the institutional interests of the CAHs themselves. 

West Virginia's criteria for the distribution of Flex Program grants emphasize community needs assessments and community involvement although the staff explained that these initiatives play out differently from hospital to hospital. West Virginia has placed major emphasis on network building in its mini-grant program. Despite this state-level emphasis, concerns have been raised about the networks developed under a rural managed care center grant during the period 1994 through 1999 as they have not proven to be self-sustaining. One source suggested that network building for its own sake is a poor investment.

CAH/Community-Level Initiatives

One hospital that we visited in New Mexico described a local perinatal providers' group that meets monthly and includes nurses from the OB unit, midwives, physicians, a nurse practitioner from an Indian Health Service clinic, and a nurse practitioner who staffs a local clinic. In addition, a local maternal and child health coalition for perinatal enrichment meets monthly with representatives from Women, Infants, and Children (WIC), Medicaid, Families First (a program of the public health department), and the mental health department. These meetings serve to provide a sort of case management role for an at-risk population.

In northern Michigan, one CAH has entered into a formal agreement with the county health department to provide culposcopy and mammography services to health department clients. They also sponsored a women's health day, also in conjunction with the county health department, that attracted 35 women from the community. The same hospital has also worked with local tribes to develop additional women's services in the community. The hospital provided the necessary physician and clinical staff and the tribes purchased equipment necessary to develop those services. The hospital's administrator and other key staff participate in the local human services collaborative board (the area's MPCB). The board meets monthly to discuss local coordination and service issues and includes representatives from the hospital, local health care and social service agencies, the health department, and the community mental health center. These activities resulted in increased utilization of the hospital's outpatient services and the development of new services for residents of the community. These outreach efforts also generated increased political support for the hospital. This support was particularly important when the renewal of its county tax support came up for vote. According to the administrator, a positive decision by the voters was far from guaranteed.

A CAH in central North Carolina is exploring public health collaborations as its emphasis shifts from increasing market share to improving access for county residents. The hospital's relationship with the health department began with the joint development of minority crisis intervention services as well as programs and services targeting the growing population of Hmong and Laotian refugees settling in its area. Another CAH in North Carolina has entered into a close relationship with the local health department in which it meets regularly with and supports part of the salary of the Director. This relationship was undertaken at the direction of the North Carolina Office of Rural Health and has resulted in a closer linkage of the hospital to the needs of the community. It has also allowed the hospital to support the local public health system in the face of recent budget cuts in North Carolina. The same hospital is also developing a diabetes program that pulls in other providers, a nurse triage program that provides off hour coverage for local physicians (thereby strengthening the relationship between the physicians and the hospital), and a school nurse program with the local schools which the school department has committed to supporting after the initial demonstration grant expires. This hospital's local networking efforts have resulted in increased inpatient and outpatient utilization as well as the maintenance of key public health functions within the county.

A West Virginia CAH has worked with a local school to develop a successful school-based clinic that is open to students and staff of the school system and their families. The clinic has been well received and treats all patients regardless of ability to pay. The hospital is currently planning to develop a clinic with a school system in an adjoining community to expand the availability of primary care services in surrounding areas. This same hospital is involved with a regional network that includes hospitals, clinics, community health centers, and birthing centers. The expanded membership has created some difficulties for the network as it is difficult to meet the diverse needs of the participants. Some fallout in membership has occurred as the hospital members perceive their needs are not being met. The hospital has also attempted to work more closely with the local Federally-Qualified Health Center (FQHC). The hospital would like to serve as the FQHC's lab vendor believing that it can offer quicker turnaround and lower costs. To date, the FQHC has rejected the hospital's proposal due to its (the FQHC's) desire to remain autonomous. Despite this fact, the relationship between the institutions seems solid as the family physicians at the FQHC perform most of the deliveries in the hospital's OB unit. The hospital and the FQHC worked together to conduct surveys and analyze data as part of a needs assessment undertaken by the hospital during its conversion. This hospital reports greater outpatient utilization within the community as well as the ability to raise significant dollars from the community ($310,000) to equip its new addition which houses it emergency room and Rural Health Clinic. It has also resulted in an expansion of services to students and staff (as well as their families) of the school in which the school-based clinic is located. Community officials have also linked the hospital to their ability to recruit and retain industry.

Before leaving this section, it will be useful to discuss (and refute) some common responses to our site visit questions about local networking efforts. Administrators often described situations in which members of their physician, nursing, or physical therapy staff were employed by local agencies (health departments, family planning programs, etc.) or providers (nursing homes, home health agencies, etc.). Conversely, they also described situations in which staff from these agencies and/or providers worked at the hospital. In exploring these relationships, it became clear that these were independent and private arrangements rather than strategic organizational collaborations. Although these linkages serve to develop some individual familiarity with local services on the part of the participating health professionals, rarely have they resulted in any changes to the local infrastructure.

Another common description of local networking provided by administrators was the systematic referral of patients to local home health agencies, nursing homes, mental health agencies, federally qualified health agencies, rural health clinics, etc. Referral of patients does not constitute a formal effort to develop new services, address access issues, or reach out to an underserved population.

A third common response was that, while no formal linkages and networking efforts were taking place at the local level between the hospital and other agencies/providers, the size and closeness of the community meant that key staff from the hospital and these organizations all knew each other and had frequent contact at various social and community functions. By virtue of these informal contacts, it was suggested that the key stakeholders in the community were aware of local access and service needs. Rarely do these "social" contacts have the impact typically ascribed to them, however, as they tend to be sporadic, unstructured, and occur in the context of some other event.

Finally, administrators tended to discuss local networking in terms of the variety of activities participated in (e.g., the number of meetings with community providers attended, the task forces served on, the needs assessments and analysis of local data conducted as part of the conversion application, etc.), rather than the attainment of specific objectives or goals. Too often, these activities, particularly meetings and task forces, seemed to be oriented more towards keeping track of the players than the accomplishment of specific tasks and goals.

Discussions and Recommendations

These characterizations of local networking efforts serve to underscore common misconceptions about networking efforts in general and local networking efforts in particular. Discussions of networking initiatives too often focus on the process of networking rather than outcomes. In other words, the focus of attention is often on such things as meetings between network participants, the collection and analysis of data, and the formation of tasks forces rather than on the development of new and needed services, the expansion of access for underserved and vulnerable populations, retention and growth of local market share, and/or the reversal of patient outmigration.

It might be argued that these process-oriented activities can be thought of as preliminary steps that can facilitate the development of relationships and trust between the CAH and community providers and agencies. While this may be true to a certain extent, these process activities are not likely to foster the development of real trust unless they are focused on the attainment of specific goals and require the formal commitment of the participants. As one respondent stated, "networks work best when focused on specific task and projects."

Given the relatively limited evidence of local networking occurring between CAHs and the agencies/providers in their communities, should incentives to encourage local networking initiatives be part of state Flex Programs? Given the potential benefits, why has there not been more activity (or more success from state initiatives)? How can states and state Flex Programs encourage CAHs to undertake these activities? What are the potential benefits to the CAH and to the local health care infrastructure?

We would argue that the Flex Program should have incentives to promote local networking. As discussed earlier, rural health care systems can be thought of as a series of concentric circles with the hospital at the center, if only because the hospital has the most resources and the most visible presence. Rural hospitals are generally the largest health care provider in their communities and, often, their counties. As such, they are frequently, but not always, looked to by other providers/ agencies as well as the general public for leadership and, in fact, are positioned to provide that leadership. As we have seen, CAHs too often look outside of their communities to larger hospitals and hospital systems for leadership and assistance. Although this may be appropriate around many administrative and operation functions, this external focus does little to bolster the CAH's standing as a community leader surrounding local health care issues. CAHs can and should provide leadership around the identification of community health care needs.

As to why we have not seen more local networking, a number of factors may help to explain the relatively low activity levels. Despite a ten-year effort by the American Hospital Association to move hospitals to a more community-oriented perspective, many hospital administrators still define their facilities by their inpatient activities. Moreover, the incentives provided under the Flex Program to undertake more extensive local networking are generally quite limited. As mentioned earlier, local networking efforts are likely to take a back seat to efforts to stabilize cash flow and prepare for conversion given the relatively precarious financial positions of many CAHs. As one CAH administrator from Oklahoma explained to us, "You don't bring the guests into the kitchen before the meal is ready." Local networking has to occur in the context of the hospital's full range of obligations and activities. It may be that CAHs must stabilize their cash flow and operations before they can focus on external networking activities in which the hospital shares the responsibility for moving the process forward. Finally, local turf and political struggles may impede local networking efforts. The administrator may have to overcome bad blood that has arisen between past administrators and other agency heads. The hard feelings often long outlast the memory of the particular issue. Other local providers may resent the dominance of the CAH in their communities or fear the loss of their own autonomy as a result of engaging in local networking activities. Effective hospital leadership often involves learning how to work effectively with smaller community agencies. The CAH administrator may have to walk a very careful line to keep the process moving without appearing to dominate it. Any one (or combination) of these factors is more than sufficient to restrain local community networking efforts.

We have also seen significant benefits to the hospitals that are engaged in local networking activities that can be attributed, at least in part, to these efforts. In addition to the expanded utilization of outpatient/ambulatory volumes, the benefits described by the hospitals include increased community and political support as well as enhanced public and private fund raising capacity. The communities in which these facilities are located have benefited by an expansion of services to their residents, a maintenance of key services, and an improved ability to recrui