Community Impact and Benefit Activities of CAHs, Other Rural, and Urban Hospitals, 2014

Non-profit hospitals, including Critical Access Hospitals (CAHs), are required to report their community benefit activities (programs and services that provide treatment and/or promote health in response to identified community needs) to the Internal Revenue Service. Using a set of community benefit indicators developed by the Flex Monitoring Team (FMT), these reports compare CAHs to non-metropolitan non-CAHs (non-metro hospitals) and metropolitan (metro) hospitals in order to monitor the community benefit activities of CAHs and understand whether and how their community benefit profiles differ from the profiles of other hospitals. The Flex Monitoring Team also produces state-specific reports with more detailed results

Community Impact and Benefit Activities of Critical Access, Other Rural, and Urban Hospitals, 2017

Non-profit and publicly-owned hospitals, including Critical Access Hospitals (CAHs), have obligations to address the health needs of their communities. Non-profit hospitals are required to report their community benefit activities to the Internal Revenue Service using Form 990, Schedule H. Community benefit activities include programs and services that provide treatment and/or promote health in response to identified community needs. Publicly-owned hospitals are also held accountable to the needs of their communities through the oversight of their governing boards and local governments. To monitor the community impact and benefit activities of CAHs and to understand whether and how their community impact and benefit profiles differ from those of other hospitals, we compared CAHs to other rural and urban hospitals using a set of indicators developed by the FMT. This report enables State Flex Programs and CAH administrators to compare the community impact and benefit profiles of CAHs nationally (Tables 1 and 2) to the performance of CAHs in their state (see links to state-specific tables on page 5). Table 1 provides data for select measures of community impact and benefit, including the provision of essential health care services that are typically difficult to access in rural communities. Table 2 provides data on hospital charity care, bad debt, and uncompensated care activities. The Flex Monitoring Team also produces state-specific reports with more detailed results

Why Do Some CAHs Close Their Skilled Nursing Facility Services While Others Retain Them? (Briefing Paper #32)

Variations in reimbursement policies and swing bed use suggest that the incentives influencing the decisions of CAHs regarding their Skilled Nursing Facility (SNF) units may differ from those of urban hospitals. Based on a review of the literature and conversations with members of the Flex Monitoring Team’s Expert Work Group, we expected the financial decision regarding SNF unit operation to be more complex for CAHs than for PPS hospitals largely because the decision involves the profitability of a PPS-reimbursed SNF within a cost-based facility. In the case of the CAH, the indirect and facility costs associated with operating a PPS-reimbursed SNF unit must be subtracted from the cost base of the cost-reimbursed acute care services thereby reducing reimbursement for those services. We also expected that the availability of swing beds (which can be used effectively to manage acute care length of stay issues without compromising acute care reimbursement) would be a significant factor in decisions to close SNF units. We identified other factors that might influence a CAH’s decision to retain a SNF unit including: the need for an alternative to swing beds to manage length of stay issues for CAHs with consistently high acute care census levels; community need and preference (which might be particularly important for municipal and county-owned hospitals); and limitations on SNF unit closure imposed by state Certificate of Need regulations. Among the potential factors influencing a CAH’s decision to close or retains its SNF units, only the latter factor (i.e., the influence of Certificate of Need regulations) was not supported by our study. We interviewed 20 CAHs operating in eleven states, including 11 hospitals that had closed their SNF units and 9 that continued to operate their services. This report discusses our findings in detail; there is also a policy brief which highlights the same findings

Rural Health Clinic Readiness for Patient-Centered Medical Home Recognition: Preparing for the Evolving Healthcare Marketplace [Working Paper]

The patient-centered medical home (PCMH) model reaffirms traditional primary care values including continuity of care, connection with an identified personal clinician, provision of same day- and after-hours access, and positions providers to participate in accountable care and other financing and delivery system models. However, little is known about the readiness of the over 4,000 Rural Health Clinics (RHCs) to meet the PCMH Recognition standards established by the National Council for Quality Assurance (NCQA). The authors present findings from a survey of RHCs that examined their capacity to meet the NCQA PCMH requirements, and discuss the implications of the findings for efforts to support RHC capacity development. Key Findings: Based on their performance on the “must pass” elements and related key factors, Rural Health Clinics (RHCs) are likely to have difficulties gaining National Center for Quality Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) Recognition. RHCs perform best on standards related to recording demographic information and managing clinical activities, particularly for those using an electronic health record. RHCs perform less well on improving access to and continuity of services, supporting patient self-management skills and shared decision-making, implementing continuous quality improvement systems, and building practice teams. RHCs are likely to need substantial technical assistance targeting clinical and operational performance to gain NCQA PCMH Recognition

Provision of Mental Health Services by Critical Access Hospital-Based Rural Health Clinics

Residents of rural communities face longstanding access barriers to mental health (MH) services due to chronic shortages of specialty MH providers, long travel distances to services, increased likelihood of being uninsured or under-insured, limited choice of providers, and high rates of stigma. As a result, rural residents rely more heavily on primary care providers and local acute care hospitals to meet their MH needs than do urban residents. This reality highlights the importance of integrating primary care and MH services to improve access to needed care in rural communities. Critical Access Hospitals (CAHs) are ideally positioned to help meet rural MH needs as 60 percent manage at least one Rural Health Clinic (RHC). RHCs receive Medicare cost-based reimbursement for a defined package of services including those provided by doctoral-level clinical psychologists (CPs) and licensed clinical social workers (LCSWs). This briefing paper explores the extent to which CAH-based RHCs are employing CPs and/or LCSWs to provide MH services, describes models of MH services implemented by CAH-based RHCs, examines their successes and challenges in doing so, and provides a resource to assist CAH and RHC leaders in developing MH services. It also provides a resource for State Flex Programs to work with CAH-based RHCs in the development of MH services. FMI: John Gale, [email protected]

Adoption and Use of Electronic Health Records by Rural Health Clinics: Results of a National Survey [Working Paper]

Rural Health Clinics (RHCs) are a vital source of primary care services with more than 4,000 clinics serving rural communities. Relatively little is known about the extent to which RHCs have adopted and are using electronic health records (EHRs) to support clinical services. Because EHR adoption is an essential element for inclusion in accountable care organizations, patient centered medical homes, and health plan provider networks offered on state and national health insurance marketplaces, EHR implementation will be increasingly important to RHCs if they are to remain competitive participants in the evolving healthcare market. Key Findings: Nearly 72 percent of Rural Health Clinics (RHCs) have an operational electronic health record (EHR), with 63 percent indicating use by 90 percent or more of their staff. Slightly over 17 percent of RHCs without an EHR plan to implement one within six months, and 27 percent plan to do so within seven to twelve months. Common barriers to EHR implementation include acquisition and maintenance costs (72 percent), lack of capital (51 percent), and concerns about productivity and income loss during implementation (45 percent). RHCs continue to lag on some meaningful use measures, but perform well on measures related to clinical care and patient management. With Regional Extension Centers facing the loss of federal funding it is important to identify additional resources to assist RHCs in maximizing EHR adoption and use

Adoption and Use of Electronic Health Records by Rural Health Clinics: Results of a National Survey [Policy Brief]

Rural Health Clinics (RHCs) are a vital source of primary care services with more than 4,000 clinics serving rural communities. Relatively little is known about the extent to which RHCs have adopted and are using electronic health records (EHRs) to support clinical services. Because EHR adoption is an essential element for inclusion in accountable care organizations, patient centered medical homes, and health plan provider networks offered on state and national health insurance marketplaces, EHR implementation will be increasingly important to RHCs if they are to remain competitive participants in the evolving healthcare market. This study demonstrates that RHCs are approaching parity with other physician practices in terms EHR adoption and use, however, some RHCs, such as provider-based clinics, report lower rates of EHR adoption than other clinics. Key Findings: Nearly 72 percent of Rural Health Clinics (RHCs) have an operational electronic health record (EHR), with 63 percent indicating use by 90 percent or more of their staff. Slightly over 17 percent of RHCs without an EHR plan to implement one within six months, and 27 percent plan to do so within seven to twelve months. Common barriers to EHR implementation include acquisition and maintenance costs (72 percent), lack of capital (51 percent), and concerns about productivity and income loss during implementation (45 percent). RHCs continue to lag on some meaningful use measures, but perform well on measures related to clinical care and patient management. With Regional Extension Centers facing the loss of federal funding it is important to identify additional resources to assist RHCs in maximizing EHR adoption and use

Community Paramedicine in Rural Areas: State and Local Findings and the Role of the State Flex Program (Policy Brief #35)

This study examined the evidence base for community paramedicine in rural communities, the role of community paramedics in rural healthcare delivery systems, the challenges faced by states in implementing community paramedicine programs, and the role of the state Flex programs in supporting development of community paramedicine programs. Additionally, the study provides a snapshot of community paramedicine programs currently being developed and/or implemented in rural areas. Another FMT briefing paper describes these same findings in detail. Highlights: Many rural community paramedicine programs are in pilot stages. Most community paramedics work within an expanded role rather than an expanded scope of practice, the latter requiring legislative or regulatory change. Funding and reimbursement for community paramedicine services are major challenges for the sustainability of community paramedicine programs. Data collection is vital for community paramedicine programs to be able to show value, including shared saving and patient outcomes. Collaboration at local and state levels is essential for buy-in, and partnering with the State Office of Rural Health is especially helpful in the early development and outreach efforts for rural community paramedicine programs

Rural Health Clinic Participation in the Merit-Based Incentive System and Other Quality Reporting Initiatives: Challenges and Opportunities

Rural Health Clinics (RHCs) are an important source of primary care in underserved rural communities with more than 4,200 RHCs providing primary care services to rural Medicare and Medicaid beneficiaries in 44 states. In light of the growing emphasis on quality reporting, it is important to understand factors influencing RHC readiness to participate in quality reporting including the Merit-Based Incentive Payment System (MIPS), Medicaid, and commercial payer quality reporting programs. The exclusion of RHCs from CMS’s quality reporting programs and value-based initiatives may potentially create a perception among consumers and policymakers that RHCs are unable to meet the requirements of these initiatives and are providing lesser quality care than larger, urban-based clinicians. To inform this brief, we conducted an extensive review of the MACRA legislation and regulations, literature on RHC quality reporting and CMS RHC billing manuals, advisory and consulting reports, and monitored listservs relevant to the topic. Additionally, we conducted key informant interviews with national and state organizations associated with RHCs. This brief outlines several challenges faced by RHCs to engage in quality reporting initiatives and highlights the opportunities to support their participation in these initiatives