Maintaining Rural Hospitals: The Critical Access Hospital Story

1
Maintaining Rural Hospitals The Critical Access
Hospital Story

• Terry J. Hill, Executive Director
• National Rural Health Resource Center

2
Technical Assistance Services Center (TASC)

• Federally designated resource center
• Funded by HRSAs ORHP
• Support Flex Program implementation in 47 states
• Located in Duluth, MN

3
Tracking Team

• U of Minnesota
• U of North Carolina
• U of Southern Maine
• U of Washington
• Project HOPE
• RUPRI

4
The Story to Tell Critical Activities Have
Begun

• Helping to create a statewide vision and
  infrastructure
• Aiding hospitals converting to CAH
• Helping communities focus on health outcomes
• Strengthening hospitals for long-term survival

5
The Story to Tell Critical Activities Have
Begun (cont.)

• Building hospital networks
• Developing quality improvement projects
• Strengthening emergency medical services

6
Creating the Statewide Vision

• As the third year of the Flex Program evolves,
  states are shifting attention and priorities to
  longer-term issues
• Refining state priorities for the Program
• Focusing on longer-term rural hospital and health
  systems performance issues
• Quality improvement
• Strategic planning

7
Creating the Statewide Vision

• Improving hospital business and operational
  performance
• Developing strategies to integrate EMS into
  health systems
• Meeting capital needs of rural hospitals
• Producing data for benchmarking CAH performance

8
Aiding Hospitals in Conversion Process

• As of January 1, 2002
• 559 certified CAHs
• 1770 hospitals received some form of assistance
• Deciding to convert
• Financial analysis
• Community service needs
• Health care system considerations

9
Location of Critical Access Hospitals
Information Gathered Through March 1, 2002
Legend
( ) N
Alaska and Hawaii not to scale.
Critical Access Hospital
(570)
Metropolitan County
Nonmetropolitan County
State Not Eligible or Not Participating
Sources CMS Regional Office, ORHP, and State
Offices Coordinating with MRHFP, 2002.
Produced By North Carolina Rural Health Research
and Policy Analysis Center, Cecil G. Sheps Center
for Health Services Research, University of North
Carolina at Chapel Hill.
10
(No Transcript)
11
CAH Facts

• Average number of beds 20
• Percent with swing beds 86
• Percent with OB 27
• Percent in underserved areas 92
• Percent with ambulances - 20

12
CAH Facts (cont.)

• Median census 3.5 patients
• Average LOS 3.4 days
• Average Medicare discharges 61.5
• Average Medicaid discharges 8.3
• Average occupancy 25

13
Who Converts?

• The strong administrators who are early
  adopters, more involved in their associations and
  more political
• The weak just plain desperate

14
Hospital Administrators

• 48 years old
• 65 male
• 35 advanced within hospital
• 51 undergrad degree
• Job tenure 5.77 yrs (/- 6.29)
• Generally good
• Director of Nursing is critical

15
Turnover

• Average hospital had two administrators in last 5
  years (range 1-9)
• 30 had more than two

16
Why Not Convert?

• Making money on DRGs
• Low-cost (low-wage, low-debt) hospitals
• Are or anticipate being gt15 beds
• Consultant reports confusing
• Fiscal intermediary problems

17
Why Not Convert? (cont.)

• Opposition (docs, community)
• Specific glitches psych units
• Cost of life-safety code improvements
• Medicaid/IHS not participating
• State not supportive

18
How are Hospitals Changing to Convert?

• Very little
• If anything, scope of services are expanding
• Using CAH to pay debt service

19
Helping Communities Focus on Health Outcomes

• As of January 1, 2002, 557 communities received
  assistance with needs assessment and community
  development
• Hospital service mix being responsive to
  community needs
• Outpatient specialty clinics
• Outpatient surgery
• Laboratory and radiology

20
Strengthening Hospitals for the Long Term

• Increase in revenue

1996
1997
Only 13 of information available.
1999
1998
2000
21
Strengthening Hospitals for the Long Term (cont.)

• Reverse decline in hospital total margins

26
18
16
11
10
9
8
7
7
5
5
2
2
1
1
1
22
Building Hospital Networks

• Majority of states require network formation for
  every CAH they certify
• Early activities of networks, descending order of
  mention in a survey
• Patient transfer agreements
• Quality assurance or improvement activities
• Referral arrangements
• Specialty services
• Administration

23
Developing Quality Improvement Projects

• Unexpectedly, we found that CAHs and states
  reported substantial interest and involvement in
  quality assurance and quality improvement
  activities despite the short amount of time they
  have been involved in the program (p.8)
• Linkages that CAHs have are valuable in quality
  improvement projects
• Network hospital
• State hospital association
• Peer review organization (PRO), now quality
  improvement organization (QIO)

24
Quality

• 16 of CAHs are JCAHO accredited
• Half the hospitals say theyve improved quality
  since conversion
• Barriers
• Low volume
• Small medical staff
• Little info systems capacity

25
State Quality Initiatives

• Nevada Consultant does on-site evaluations of
  each CAH, sends written report and
  recommendations
• Montana Contractor created standardized
  policies and procedures for CAHs
• Idaho Uses MQIP
• Arkansas PRO looks at 4 DRGs, 11 performance
  indicators for each CAH

26
Strengthening Emergency Medical Services (EMS)

• Training initiatives
• Clinical training for EMS personnel, including
  hospital personnel and medical directors
• Management, billing, and data entry
• Needs assessments
• Encouraging local collaboration
• Enhancing data collection and reporting systems

27
EMS

• Most CAHs do not operate EMS systems
• 2/3 of CAHs send RNs on inter-facility transfers
• 3/4 said conversion had no impact where there
  was an impact, it was likely to be positive
• Appreciate initiatives being supported with grant
  money

28
EMS

• Most CEOs believe their EMS systems work well
• But there are still problems
• Recruitment and retention
• Funding and reimbursement
• Training

29
Findings

• Program provides financial breathing room to
  rural hospitals
• Cost-based reimbursement encourages capital
  improvements
• Hospitals may be cutting beds but arent
  shrinking services
• Some networks are really working

30
Findings

• Conversion appears to be associated with an
  improvement in financial condition
• Long-term effects of program on CAH viability are
  not yet known
• Economic impact on communities is proving to be
  important

31
Findings

• Flex Program is more than just CAHs
• Building infrastructure in state offices helps
  all rural health activities
• This program has infused energy into many
  efforts
• Community development
• EMS
• Quality
• Networking

32
More Findings

• There remain formidable barriers to conversion
  (distinct part units, life safety costs,
  Medicaid, FIs, IHS)
• CAH and long-term care policies arent well
  aligned
• Quality getting more attention than expected

33
Building a Better Future

• The reauthorization and continuing
  implementation of the Flex Program represents an
  opportunity to further assist states, rural
  hospitals, and rural communities to continue to
  develop innovative strategies and technical
  assistance programs for stabilizing and
  strengthening rural hospitals and community
  health systems. (Findings From the Field, Vol.
  2, No. 5)

34
Rural Health Planning and Policy Development

• Continue to support role of the states in
  partnerships with others, including state
  hospital associations, to monitor and update
  statewide planning and policy development
• Provide incentives and support for states to
  track and assess the status of vulnerable rural
  communities and hospitals

35
Rural Health Planning and Policy Development
(cont.)

• Continue and expand the function of technical
  assistance for small rural hospitals, rural
  networks, and communities
• Continue to support forum for exchange of
  information among states, hospitals, and other
  Program participants
• Support continued tracking and assessment

36
Expand Rural Network Development

• Encourage and support partnerships among rural
  hospitals and their partners, community
  organizations, and rural networks
• Expand training and networking opportunities for
  CAH administrators and other hospital staff
  (including medical director), including an
  understanding role of the hospital in the
  community health system

37
Expand Quality Improvement

• Encourage states, hospitals, and communities to
  include quality improvement initiatives as a core
  component in other activities (network
  development, EMS)

38
Strengthen Rural EMS

• Encourage development of EMS as a critical
  component of hospital care through expanded
  partnerships of EMS provider organizations with
  other providers and inclusion of EMS in rural
  health network development

39
Expand Hospital Technical Assistance

• Encourage and support performance initiatives
  that expand and improve management and fiscal
  capacity, including strategic planning, practice
  management assistance, peer assistance programs
  for CAH administrators, and other activities.

40
Conclusion

• Modest investment
• Evolving program
• Flexibility is beneficial in this federal program
• Could help secure the future