Innovations in Rural Health System Development: Governance

This series of briefs were produced by the Maine Health Access Foundation (MeHAF) in conjunction with the Maine Rural Health Research Center to describe robust and innovative models and strategies from Maine and other parts of the country related to the areas of health finance and payment, governance, workforce, and service delivery that have the potential to be replicated or adapted here in Maine. Other briefs in this series: Moving Rural Health Systems to Value-Based Payment Recruiting and Retaining Maine\u27s Health Care Workforce Maine\u27s Behavioral Health Services Service Delivery Advances in Care Coordination Emergency Care, and Telehealth Federally Qualified Health Center Initiatives Learn more at www.mehaf.or

Innovations in Rural Health System Development: Moving Rural Health Systems to Value-based Payment

This series of briefs were produced by the Maine Health Access Foundation (MeHAF) in conjunction with the Maine Rural Health Research Center to describe robust and innovative models and strategies from Maine and other parts of the country related to the areas of health finance and payment, governance, workforce, and service delivery that have the potential to be replicated or adapted here in Maine. Other briefs in this: Recruiting and Retaining Maine\u27s Health Care Workforce Governance Maine\u27s Behavioral Health Services Service Delivery Advances in Care Coordination, Emergency Care, and Telehealth Federally Qualified Health Center Initiatives Learn more at www.mehaf.or

Promising Flex Program Initiatives to Support Critical Access Hospitals during the COVID-19 Pandemic

This brief reports on promising State Flex Program (SFP) strategies to support Critical Access Hospitals during the COVID-19 pandemic. SFPs adapted existing initiatives and implemented new activities to address the emerging needs of CAHs during the pandemic. With approval from the Federal Office of Rural Health, the SFPs redirected funds and activities to address the evolving COVID-19 needs of CAHs while maintaining fidelity to Flex Program goals. Based on qualitative interviews with seven SFPs, the authors, members of the Flex Monitoring Team, discuss initiatives such as resiliency training for frontline staff; packaging and dissemination of COVID-19 information; public health messaging; infection prevention and pharmacy consultations; and financial technical assistance and programs. The authors also highlight ongoing COVID-19 needs of CAHs as described by the SFPs, which include increased financial vulnerability, rural workforce shortages, and support for telehealth. FMI: Celia Jewell, [email protected]

Evaluating State Flex Program Population Health Activities

The Medicare Rural Hospital Flexibility (Flex) Program funds initiatives to improve the health of rural communities under Program Area 3: Population Health Improvement, in order to build the capacity of Critical Access Hospitals (CAHs) to achieve measurable improvements in the health outcomes of their communities. Th authors provide an overview of the expectations for Program Area 3; summarize State Flex Program (SFP) initiatives under this Program Area; describe promising population health strategies implemented by SFPs; and discusse outcome measurement issues for population health, including providing an example a chain of short, intermediate, and long-term outcome measures for a potential population health activity. Th authors also portray a pathway to connect Flex Program population health efforts to the U.S. Department of Health and Human Services’ Healthy Rural Hometown Initiative (HRHI), a five-year multi-program effort to address the factors driving rural disparities in heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke. Finally, the brief provides resources for outcome measurement in population health. A companion brief, An Inventory of State Flex Program Population Health Initiatives for Fiscal Years 2019-2023, provides a detailed description of population health initiatives proposed by the 45 SFPs. This brief is available at: https://www.flexmonitoring.org/sites/flexmonitoring.umn.edu/files/media/InventoryofSFPPopHealthActivities_0.pdf For more information, please contact John Gale at [email protected]

Innovations in Rural Health System Development: Federally Qualified Health Center Initiatives

Part of a series of briefs profiling innovative rural health system transformation models and strategies from Maine and other parts of the US, this brief focuses on promising strategies of federally qualified health centers. These strategies include workforce recruitment and retention initiatives, approaches to serving high-need patient populations, services to address the opioid crisis and dental care, and innovations in providing enabling services that address the social determinants of health. This series on Innovations in Rural Health System was funded by the Maine Health Access Foundation. Other briefs in this series include: Moving Rural Health Systems to Value-Based Payment Recruiting and Retaining Maine\u27s Health Care Workforce Governance Maine\u27s Behavioral Health Services Service Delivery Advances in Care Coordination, Emergency Care, and Telehealth Learn more at www.mehaf.or

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]

Engaging Critical Access Hospitals in Addressing Rural Substance Use

Substance use is a significant public health issue in rural communities. Despite this fact, substance use treatment services are limited in rural areas and residents suffer from significant barriers to care. Critical Access Hospitals (CAHs), frequently the hubs of local systems of care, can play an important role in addressing substance use disorders. To develop a coordinated response to community substance use issues, CAHs must identify and prioritize local needs, mobilize local resources and partnerships, build local capacity, and screen for substance use among their patients. These activities provide a foundation upon which CAHs and their community partners can address identified local needs by selecting and implementing initiatives to minimize the onset of substance use and related harms (prevention), treat substance use disorders, and help individuals reclaim their lives (recovery). This brief makes the case for why CAHs should address substance use, provides a framework to support CAHs in doing so, describes examples of substance use activities undertaken by CAHs to substantiate the framework, and identifies resources that can be used by State Flex Programs to support CAHs in addressing this important public and population health problem

Addressing Opioid Use in Rural Communities: Examples from Critical Access Hospitals

The opioid epidemic continues to have a devastating impact in rural areas disproportionately affected by a lack of infrastructure to provide treatment for opioid use disorders (OUDs). Critical Access Hospitals (CAHs), often the hubs of local systems of care, can play an important role in addressing OUDs. Using a substance use framework developed for the Flex Monitoring Team’s earlier study of CAH substance use strategies, this brief highlights strategies adopted by CAHs to combat opioid use in their communities. It also identifies resources that State Flex Programs can use to support CAHs with this challenging population health issue

Population Health Outcome Measurement Strategies for State Flex Programs

This brief on population health outcome measurement strategies for State Flex Programs (SFPs) targets an important need – the ability to monitor and document the impact of the Flex Program over time. This is an area in which SFPs have struggled for some time. This brief presents a framework that connects the activity categories under the population health program area into a strategic process within individual project years as well as across the project funding cycle. This framework consists of a series of steps that move sequentially from identifying the needs to be addressed, educational programing to prepare participants to engage in proposed interventions, development of shared learning collaboratives/cohorts to support performance improvement, and the implementation of interventions to address identified needs. It further provides practical examples of population health improvement activities with short, intermediate, and long-term outcomes necessary to document program impact over time. It also connects these activities through examples of a causal pathway with subsequent activities building on early activities to move toward desired long-term goals

Outcome Measures for State Flex Program Financial and Operational Improvement Interventions

This brief provides a detailed look at outcome measurement issues for State Flex Program (SFP) interventions conducted under Program Area 2: Financial and Operational Improvement (FOI), a mandatory area of SFP activity. It presents a set of short- and intermediate-term FOI measures for common categories of FOI interventions. Given that SFPs tend to focus primarily on output and long-term, high-level outcome measures, these short- and intermediate-term outcome measures provide a bridge between project activities and long-term outcomes within the course of the funding cycle. The brief describes a set of common FOI interventions as well as the theory of change and a set of short- and intermediate term measures for each intervention. Efforts to document the impact of SFP initiatives on Critical Access Hospital (CAH) performance would be supported by: • Implementing collaborative learning initiatives to provide a unified, structured framework to coordinate SFP FOI activities across the Flex Program funding cycle. • Reducing the emphasis on outputs and increasing the emphasis on short-, intermediate-, and long-term outcome measures. • Structuring SFP requests for proposals to request that contractors identify short-, intermediate-, and long-term outcome measures; baseline data; actionable outcome targets; and a realistic timeline to reach performance targets as part of their work products. A companion brief (https://www.flexmonitoring.org/publication/monitoring-state-flex-program-financial-and-operational-improvement-activities) provides an inventory of all SFP FOI initiatives and a more detailed analysis of the interventions undertaken by a subset of 14 SFPs. FMI: John Gale, [email protected]