Download Minnesota Medicare Rural Hospital Flexibility Program: Program Evaluation Second Interim Report

Minnesota Medicare Rural
Hospital Flexibility Program
NORTH
STAR
Program Evaluation
Second Interim Report
April 2002
A report from the Minnesota Department of Health
Rural Hospital Flexibility Program Evaluation
Second Interim Report
Prepared for
MINNESOTA MEDICARE RURAL HOSPITAL
FLEXIBILITY PROGRAM ADVISORY COMMITTEE
AND THE FEDERAL HEALTH RESOURCES AND SERVICES
ADMINISTRATION (HRSA),
OFFICE OF RURAL HEALTH POLICY
April 2002
Minnesota Department of Health
Community Health Services Division
Office of Rural Health and Primary Care
Rural Hospital Flexibility Program Evaluation
Second Interim Report
Prepared for
MINNESOTA MEDICARE RURAL HOSPITAL
FLEXIBILITY PROGRAM ADVISORY COMMITTEE
AND THE FEDERAL HEALTH RESOURCES AND SERVICES
ADMINISTRATION (HRSA),
OFFICE OF RURAL HEALTH POLICY
For more information about this report, contact:
Minnesota Department of Health
Community Health Services
Office of Rural Health and Primary Care
P.O. Box 64975
St. Paul, Minnesota 55164
(651) 282-3838
FAX: (651) 297-5808
Minnesota Relay Service
1 (800) 627-3529
In Greater Minnesota:
1 (800) 366-5424
http://www.health.state.mn.us/divs/chs/orh_home.htm
Rural Hospital Flexibility Program Evaluation
Second Interim Report
Office of Rural Health and Primary Care
Minnesota Department of Health
St. Paul, Minnesota
April 2002
Funded by the Office of Rural Health Policy,
U.S. Department of Health and Human Services
TABLE OF CONTENTS
EXECUTIVE SUMMARY OF YEAR 2 FINDINGS .......................................................ii
CHAPTER 1: INTRODUCTION, BACKGROUND, AND METHODS....................... 1
THE FLEX PROGRAM........................................................................................ 2
MINNESOTA-SPECIFIC VARIATIONS IN THE FLEX PROGRAM............. 5
Certification as Necessary Provider of Health Care Services........... 5
Rural Health Networks............................................................................. 5
EVALUATION METHODOLOGY AND DATA ................................................. 5
Case Studies............................................................................................. 5
Comparisons ............................................................................................. 6
Monitoring Reports ................................................................................... 7
Site Visits, Telephone Interviews, and Targeted Surveys ................. 7
Financial and Other Secondary Data .................................................... 8
CHAPTER 2: IMPLEMENTATIO N OF THE MEDICARE RURAL HOSPITAL
FLEXIBILITY PROGRAM ................................................................................... 9
OFFICE OF RURAL HEALTH AND PRIMARY CARE IMPLEMENTATION
ACTIVITIES ............................................................................................... 9
Flex Program Support and Management ...........................................10
Grants to Hospitals and Communities ................................................12
Technical Assistance and Communications ......................................21
CHAPTER 3: PHYSICIAN INTEGRATION AND SATISFACTION ........................25
CHAPTER 4: QUALITY OF CARE ..............................................................................31
CERTIFICATION SURVEY ANALYSIS ..........................................................31
COMPLIANCE WITH QUALITY ASSURANCE AND PERFORMANCE
IMPROVEMENT PLANS.......................................................................32
CHAPTER 5: RESIDENT ACCESS AND SATISFACTION WITH CAHS .............35
COMMUNITY FOCUS GROUPS ....................................................................35
CAH MARKET SHARE .....................................................................................40
CHAPTER 6: NETWORK DEVELOPMENT ..............................................................43
CHAPTER 7: EMS DEVELOPMENT AND INTEGRATION....................................47
CHAPTER 8: FINANCIAL PERFORMANCE OF CAHs ...........................................51
BASELINE COMPARISONS ............................................................................51
FIRST-YEAR COMPARISONS ........................................................................54
APPENDIX A: EVALUATION DESIGN OVERVIE W
APPENDIX B: COMMUNITY FOCUS GROUP SUMMARIES
i
EXECUTIVE SUMMARY OF YEAR 2 FINDINGS
This report summarizes the experiences of the Minnesota Rural Hospital Flexibility
Program during Year 2. It is divided into eight chapters. The first chapter gives an
overview of the program and the evaluation plan. Chapter 2 focuses on the activities of
the Office of Rural Health and Primary Care (ORHPC) in continuing the implementation
of the program in Minnesota. The remaining chapters each focus on a specific aspect
of the Flex Program, for example, networking, quality assurance, and financial
performance of Critical Access Hospital (CAHs).
In the first year of the program, two facilities converted to Critical Access Hospital (CAH)
licensing status. In Year 2, the ORHPC designated seven additional CAHs for
certification and one more was ready for designation at the end of the program year. All
eight Year 2 facilities were certified by the Health Care Financing Administration
(HCFA, renamed the Centers for Medicaid and Medicare Services or CMS) during or
shortly after the end of Year 2. The first ten CAHs comprise the CAH study, which is a
multi-year evaluation. Quantitative and qualitative data were gathered from these
facilities involving both primary and secondary data. Data were collected for the year
before conversion, the year following conversion, and during annual follow-ups. For
some evaluation components, the performance of the CAHs was compared to a control
group of similar hospitals (i.e., CAH eligible hospitals). The evaluation is designed to
gather the relevant information needed to assess and monitor progress in
implementation of the Flex program in Minnesota, while minimizing the time that local
hospital staff must spend in completing evaluation documents and interviews. In
addition, the community focus groups conducted as part of the evaluation involve the
community in the evaluation process and allow community members to share their
experiences concerning the local health care system in a structured setting.
Findings for Year 2 are summarized below.
IMPLEMENTATION OF THE FLEX PROGRAM (Chapter 2)
• The ORHPC has continued to target hospitals that would most likely benefit from the
Flex Program. In partnership with the Minnesota Hospital and Healthcare
Partnership (MHHP), the office has engaged in numerous activities to make target
hospitals aware of the program and its possible benefits. This is demonstrated by
the increase in the number of hospitals that sought information about CAH
designation, grants for assistance in the conversion decision-making process, and
the increase in the number of hospitals that converted to CAH during Year 2 than in
Year 1.
• The ORHPC effectively organized staff and other resources to implement the Flex
Program in Minnesota, focusing on program management, awarding grants, and
providing direct technical assistance to hospitals and communities.
• The ORHPC awarded 44 grants to 38 CAH-eligible hospitals, two EMS consortia,
one hospital network, two hospital and clinic consortia, one nursing home, and one
local public health agency, financing 67 distinct projects. This work built on the
foundation of the 37 grants to 30 hospitals that were awarded in Year 1. Eight of the
ii
•
•
hospitals receiving grants in Year 2 were certified as CAHs before the end of the
year. In addition, a number of hospitals receiving Year 2 grants had applied for
conversion before the end of Year 2 or shortly thereafter. The grants appear to have
played a key role in the decision to convert and planni ng for conversion. Interviews
with administrators from the Year 2 CAHs confirmed this, with descriptions of the
role of the grants as “critical” and “extremely critical” in establishing decision criteria,
gathering relevant data, and making the conversion decision.
Grants made to hospitals and communities in Year 2 focused primarily on
conversion assessment and planning, community needs assessment, development
and enhancement of rural health networks, staff and community education, and a
number of specific projects in the areas of EMS, telemedicine, wellness, and trauma
system development.
The ORHPC provided a wide variety of communication and technical assistance
services to eligible hospitals. There appears to be a relationship between
conversion and the amount of technical assistance provided by the ORHPC. This
relationship suggests that support from the ORHPC increases immediately before
and after conversion. Administrators from the hospitals that converted during Year 2
all rated the assistance provided by the ORHPC as 9-10 (on a scale of 1 to 10, with
10 being very helpful). Assistance included clarification of regulations, survey
guidelines, immediate information and resources, and information such as that
provided in the ORHPC Critical Access News publication. One administrator said
the staff of “ORHPC were the teachers and we were the students out here who
wanted to learn. “ Another administrator noted that he regretted not using the
available services because he felt that the process would have gone “a lot more
smoothly.”
PHYSICIAN INTEGRATION AND SATISFACTION (Chapter 3)
• Of the Year 2 CAHs, more than one-third employed their medical staff and two -thirds
had offices on land owned by or adjacent to the hospital. This is a much higher
proportion of employment of medical staff members by the CAH and a higher
proportion with offices adjacent to the hospital leading to staff integration into the
CAH than Year 1 CAHs.
• Over two-thirds of the medical staff at Year 2 CAHs felt fully informed about
conversion, 19% felt informed but would have liked more information, and 7% felt
that information was not adequately shared. Given the much higher number of
practitioners in the Year 2 CAHs than Year 1, the number of staff who felt fully
informed about CAH conversion continues to remain high. Similarly, a high
proportion of CAH staff fully supported conversion, with only 2.3% being opposed.
• As in Year 1 CAHs, Year 2 CAH medical staff members expected that the
conversion would benefit the hospital and community more than their own practices.
However, unlike staff at Year 1 CAHs, more of the staff at Year 2 CAHs expected
some benefit to their practices, and 9.3% reported an increase in their practices.
• Overall, the vast majority of CAH medical staff was satisfied with the hospital, the
primary referral hospital, and their practices in the community. There was less
satisfaction with the quality assurance networking arrangements with other facilities
(about 50%) and somewhat less satisfaction (about 40%) for credentialing and
patient referral and transfer.
iii
QUALITY OF CARE (Chapter 4)
• The eight CAHS seeking certification in Year 2 passed their initial surveys with no
difficulties. Seven of the CAHs made use of the mock surveys conducted by the
ORHPC.
• Of the eight Year 2 CAHs, only three received their re-certification survey after one
year. This was primarily due to budget constraints in the survey office. One of the 3
CAHs was cited for deficiencies, which were related to the role of mid-level
practitioners and inclusiveness in the policy development process.
• Most of the Year 2 CAHs submitted examples illustrating the facility’s quality
assurance program and its ability to identify problems, develop and implement
interventions, and measure results.
• The CAHs’ communities are vaguely aware of the change in licensing status of the
CAHs, and the communities highly rate the care provided by the CAHs. These
opinions may be considered indicators of quality.
• As with Year 1 CAHs, no significant problems with quality of care were identified at
the Year 2 CAHs in the year following conversion.
RESIDENT ACCESS AND SATISFACTION (Chapter 5)
• Year 2 CAH communities continue to be supportive of the conversion to a CAH. As
was the case with Year 1 CAHs, the actual “limitations” of the model (e.g., bed size,
average length of stay) are little noted by community residents. Instead, they view
the program as an expansion of the previously existing services, through networking
arrangements, greater availability of diagnostic testing and specialist appointments,
enhanced EMS, and improved reimbursement.
• Overall, the residents of the Year 2 communities had highly favorable opinions of the
quality of care provided and the access to services.
• Access was particularly important in communities such as Community E, who
frequently lose access to services due to annual spring flooding. Access was
especially important to Community I, which is just starting to see a stable physician
base after nearly 15 years of physician turnover (see Appendix B for Community
Focus Group summaries).
• Of the Year 2 CAHs for which data were available, the market share declined slightly
in the year of conversion, though an increase in the number of patients was seen.
There was not a pronounced use of urban hospitals as was seen in Year 1 CAHs,
but an increase in the use of other rural hospitals was noted. It is unclear at this
time if this change was related to the CAH network affiliations.
NETWORK DEVELOPMENT (Chapter 6)
• The Year 2 CAHs continued existing relationships with their primary referral
hospitals and in some cases these relationship were written into formal agreements.
• CAHs are involved in a number of agreements for patient transfer and referral,
clinical services, credentialing, quality assurance, purchasing, and emergency
transportation. Some CAHs are involved in multiple agreements in one or more of
these areas.
• The CAH administrators are primarily satisfied with the networking relationships.
Many of them expected few changes in these relationships after CAH designation.
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•
•
•
Most of the changes were for additional enhancements. There were some additional
costs reported related to peer review.
No changes were made in networking relationships in the first year after CAH
designation, suggesting that fundamental aspects of the relationship did not change.
All eight Year 2 CAHs are integrated substantially by virtue of their diverse
networking relationships. This integration with full-service, acute care hospitals, as
well as other networking partners, helps to insure the local availability of services
and the quality and efficiency of such services.
Based on the additional observations from the Year 2 CAHs, the Flex Program
appears to have resulted in little substantive change in networking behavior of rural
hospitals. The network relationships are more formalized than before CAH
designation and some additional services have been added, but these seem to be a
continuation of networking activities that were in process prior to conversion.
EMS DEVELOPMENT AND INTEGRATION (Chapter 7)
• The EMS plans of all eight Year 2 CAHs satisfy the requirements of designation.
None of the CAHs made significant amendments to their EMS Plans in the first year
of operation.
• In the year of conversion, the number of emergency room (ER) visits to the CAHs
grew by eleven percent (controlling for one CAH that added urgent care services).
This is consistent with ER changes seen in Year 1 CAHs. Emergency room
transfers remained almost unchanged, with less than a one percent reduction.
Finally, acute care transfers dropped by almost six percent; at this time it is unclear
what role the 96 hour annual average length-of-stay may play in this drop.
• Year 2 CAHs remain strongly integrated with EMS and report good relationships with
EMS providers. One CAH reported an improved relationship with the EMS provider
following conversion.
FINANCIAL PERFORMANCE (Chapter 8)
• Before conversion, the Year 2 CAHs were larger than the comparison hospitals but
showed lower average daily census and total patients days than a group of
comparison hospitals. Even though they were larger, they had lower revenues and
expenses than those of the comparison group.
• In the year of conversion, the average daily census increased in the Year 2 CAHs,
while it remained relatively flat at comparison hospitals.
• During the year of conversion, Year 2 CAHs increased their net patient revenues by
2% over the comparable hospitals.
• Based on the information available, conversion to CAH appears to have increased
revenues for the Year 2 CAHs.
v
CHAPTER 1
INTRODUCTION: BACKGROUND AND METHODS
The Balanced Budget Act of 1997 created the Medicare Rural Hospital Flexibility
Program, which will be referred to as the “Flex Program” throughout this report.
Technical corrections to the Flex Program were made in 1999 by the Balanced Budget
Refinement Act and the Medicare, Medicaid, and the State Children’s Health Insurance
Program (SCHIP) Benefits Improvement and Protection Act in 2000. The Flex Program
features a new category of rural hospital called the Critical Access Hospital (CAH). A
CAH has unique licensing and certification rules, receives reimbursement from
Medicare for the cost 1 of providing inpatient and outpatient services to Medicare
beneficiaries, and must operate within a rural health network. A rural health network is
defined as an arrangement between a CAH and another hospital regarding patient
referral and transfer; development and use of communication systems; provision of
emergency and non-emergency transportation; and credentialing and quality assurance.
The Flex Program also encourages CAHs to integrate services with other local
providers such as physicians and emergency medical services providers.
The Health Care Financing Administration (HCFA, renamed the Centers for Medicaid
and Medicare Services or CMS) authorized the State of Minnesota to participate in the
Flex Program in July 1998. The first CAH in Minnesota, Mahnomen Health Center in
Mahnomen, was certified on February 2, 1999. There are approximately 80 hospitals
in Minnesota with 50 or fewer beds that are geographically eligible to apply for CAH
designation. It is estimated by the ORHPC that approximately 65 of these are likely to
convert to CAH based on current program eligibility requirements. To date, 31 hospitals
have converted to CAH and approximately 24 more eligible hospitals in the state have
expressed interest in the program.
The purpose of this report is to summarize the experience of the Flex Program in
Minnesota through the second year, and to draw lessons from that experience for the
future administration of the program. In Year 1, only two hospitals converted to CAH
status, so the number of observations was limited. For the Year 2 report, eight more
CAHs have been added to the study in order to extend the “lessons learned” from their
experiences in the Flex Program. Baseline measurements of the financial, utilization,
and networking experiences of comparison hospitals were taken during Year 1.
Additional baseline information was gathered on the Year 2 CAHs for the year before
conversion.
The remainder of this chapter provides an overview of the Flex Program, stressing both
federal provisions and those that are unique to Minnesota. A summary of the
methodology and data sources used is also presented. Chapter 2 discusses the
1
The cost-reimbursement rules of Medicare stipulate that providers will be paid the “reasonable cost” of delivering
covered services to beneficiaries. In defining which costs are “reasonable,” the Health Care Financing
Administration (now CMS) has judged some classes of expenses to be “non-allowable”—costs not directly
connected to the provision of covered services to beneficiaries. Therefore, the total legitimate costs of a CAH are
not reimbursed under current Medicare cost finding rules.
1
implementation of the Medicare Rural Hospital Flexibility Program by the Minnesota
Department of Health, Office of Rural Health and Primary Care (ORHPC). Chapter 3
investigates the satisfaction of physicians with implementation of the model and the
extent to which physicians have been integrated into the CAH model. Chapter 4
assesses the quality of care provided in CAHs and Chapter 5 assesses community
satisfaction, perceptions of care, and utilization. The sixth chapter considers rural
health networking, exploring whether the Flex Program created new linkages and what
the effect of the linkages has been. Chapter 7 assesses the impact of the program on
the local EMS system. Normally, a final chapter on the financial performance of CAHs
would be included to examine the question of whether cost-based reimbursement is
more advantageous for CAHs than Medicare prospective payments. However, due to
changes in the schedule of due dates for Medicare cost reports, these data are not yet
available. Instead, Chapter 8 includes an abbreviated look at the financial picture of
Year 2 CAHs. A more complete analysis of all of the first 10 CAHs will be covered in
next year’s evaluation report.
THE FLEX PROGRAM
The Labor, Health and Human Services, and Education Appropriations Bill for 1999
Conference Report (October 1998) stated the goals of the Flex Program:
This program will provide grants to states to help them improve access to essential
health care services in rural communities by: (1) developing and implementing a
rural health plan; (2) developing networks; (3) designating CAHs; and (4) improving
rural emergency medical services and other activities. It will provide support for local
citizens, employers, and health care providers to conduct community development
activities that are necessary to identify their health care needs and design systems of
care to address them. For hospitals and other providers, this program will provide
technical assistance and support to: (1) develop integrated networks of care; (2)
examine the conversion to CAH; (3) improve information systems, quality assurance
programs, and other activities.
The Flex Program is composed of two parts: a grant program and an operating
program. The grant program is administered nationally by the Office of Rural Health
Policy (ORHP) and the operating program is administered by the Health Care Financing
Administration (now CMS). The grant program focuses on activities that support
conversion and implementation of CAHs and rural health networks. The Minnesota
Department of Health, Office of Rural Health and Primary Care, received grants from
ORHP beginning in May 1999 to begin program planning and has received additional
grants for program continuation. From these funds, the ORHPC has awarded grants to
rural hospitals since 1999 to help them assess the feasibility of conversion, educate the
community, and apply for CAH designation. In addition to designation-related activities,
projects funded by this grant addressed regionalization of health care services, the
development and enhancement of rural health networks, workforce training and
shortages, consumer and staff education, and emergency medical services issues. The
totals of these grants are shown in Table 1.1.
2
Table 1.1
Flex Grants Awarded to Minnesota and Amounts Distributed to Hospitals
Minnesota Grant
From ORHP
Amount Distributed to
Rural Hospitals &
Communities
May 1999
$200,000
$120,000
September 1999
$550,138
$330,000
September 2000
$720,000
$506,000
September 2001
$700,000
$445,000
Date
The operating program focuses on facility regulations and Medicare payment issues for
CAHs. The facility regulations and Medicare payment policies of the operating program
were developed to improve the administrative and clinical performance of rural hospitals
choosing to convert to CAH status. Table 1.2 summarizes the program requirements
for CAHs.
3
Table 1.2
CRITICAL ACCESS HOSPITAL FACILITY REQUIREMENTS
Criteria for Designating CAHs
• Is located in a state participating in the Flex Program.
• Is designated by the state.
• Is currently licensed by the state as a hospital, or is a hospital that is closed or
downsized to a health center or clinic within the past ten (10) years.
• Is located in a rural county or an area of an urban county classified as rural
by the Secretary of Health and Human Services.
• Is located more than a 35-mile drive from another hospital or is certified by
the state as a necessary provider of heath services to residents of the area.
Service Criteria
• Makes available 24-hour emergency care services that a state determines are
necessary.
• Operates no more than fifteen (15) acute beds and up to ten (10) swing beds.
• Maintains an average length-of-stay of 96 hours or less on an annual basis.
• Provides dietary, pharmacy, laboratory, and radiological services on either a fulltime, on-site basis or part-time, off-site basis under arrangement with another
provider.
Networking Relationships
• Enters into networking agreements with at least one (1) hospital with respect to:
Ø Patient referral and transfer.
Ø Communication systems (including, where feasible, telemetry systems and
electronic sharing of patient data).
Ø Emergency and non-emergency transportation.
Ø Enters into networking agreements for credentialing of medical staff and quality
assurance with at least one hospital, one peer review organization or equivalent
entity, or other appropriate and qualified entity identified by the state.
• Personnel/Staffing Criteria
• Meets staffing requirements of other rural hospitals except the following:
Ø Need not meet hospital standards for hours or days of operation, as long as it
meets the requirement to provide 24-hour emergency care.
Ø Services of a dietician, pharmacist, laboratory technician, medical technologist,
and radiological technologist may be furnished on a part-time, off-site basis.
Ø Required inpatient care may be provided by a physician assistant or nurse
practitioner, subject to the oversight of a physician who need not be present in
the facility.
• Medicare Reimbursement
• The amount of payment for inpatient hospital services is the reasonable cost of the
CAH in providing such services.
• The amount of payment for outpatient services is the reasonable cost of the CAH in
providing such service plus (for those CAHs including professional services within
outpatient CAH services) a fee-schedule payment (i.e., resource-based relative
value scale (RB-RVS) payments) for professional services.
SOURCE: BBA, 1997
BBRA, 1999
4
MINNESOTA-SPECIFIC VARIATIONS IN THE FLEX PROGRAM
The Flex Program affords the states authority to tailor some portions of the program to
accommodate local circumstances. One of the primary areas of flexibility is the criterion
concerning the location of the facility. The federal program requires that a CAH be
located more than a 35-mile drive from a hospital or another CAH, or be certified by the
state as a necessary provider of health care services to residents in the area. In
recognition of the limitations to access imposed by geography and weather, Minnesota
Law established a necessary provider definition unique to the state.
Certification as a Necessary Provider of Health Care Services
The Minnesota-specific necessary provider definition recognizes the burden that
isolation and a shortage of medical providers has on access to health care services.
Minnesota’s necessary provider definition is:
Necessary providers of health care services are designated as CAHs on the basis of
being more than 20 miles, defined as official mileage as reported by the Minnesota
Department of Transportation, from the next nearest hospital or being the sole
hospital in the county or being a hospital located in a designated medically
underserved area (MUA) or health professional shortage area (HPSA) or located in a
county contiguous to a county with a HPSA or MUA. A CAH located in a designated
medically underserved area or health professional shortage area shall continue to be
recognized as a CAH in the event the medically underserved area or health
professional shortage area designation is subsequently withdrawn (Minnesota
Statutes 1999, 144.1483(11).
Rural Health Networks
Rural health networking is a long -established practice of rural providers in Minnesota.
The ORHPC has supported network development in recent years through the provision
of technical assistance and grants. CAHs are required to have a network agreement
that links the CAH with another larger hospital. The federal Office of Rural Health Policy
also encourages CAHs to network their services locally, an arrangement sometimes
referred to as local integration. Year 2 networking activities will be discussed in detail in
Chapter 6 of this report.
EVALUATION METHODOLOGY AND DATA
A variety of methods and data sources are used in the evaluation. (See “Minnesota
Rural Hospital Flexibility Program Evaluation Plan, February 2000,” for a complete
explanation of methods and data.) Some evaluation questions are addressed using
primary data obtained through on-site inte rviews, focus groups, telephone interviews,
and monitoring reports. The remaining questions are answered using secondary data
(i.e., data collected for another purpose that is made available to the evaluators).
Case Studies
The evaluation focuses on monitoring salient aspects of program implementation at
ten CAHs over a multi-year period. The original evaluation plan called for five CAHs
to be selected in Year 1 and five in Year 2. Because only two CAHs were certified in
5
Year 1, eight CAHs were selected for case studies in Year 2. The case-study
facilities/communities were site visited as soon as possible following conversion; a
second visit will take place approximately 24 months following the first visit. A
simplified schedule for CAHs entering the evaluation program and for subsequent
monitoring is depicted in Table 1.3. CAH progress toward achieving the operating
goals of the program will be monitored (with data assembled from monitoring reports,
secondary data analysis, and site visits), documented, and summarized in case
studies using a multiple case study evaluation design.
Table 1.3
Case Study Data Collection Schedule
Case
Study
Facility
2000
2001
2002
CAH 1- 2
First site visit
Baseline data
Follow-up data
Second site visit
Follow-up data
First site visit
Baseline data
Follow-up data
CAH 3 – 10
2003
Second site visit
Follow-up data
Comparisons
For some components of the evaluation, data will be collected for every CAH.
Trends in the data reported will be analyzed and interpreted. The data to be
collected are listed in Table 1.4.
Table 1.4
Data Collection Schedule from All CAHs and
Comparison Hospitals
Facility
2000
All CAHs
Historical and
current financial
and utilization
reports, network
diagrams, EMS
documentation,
monitoring
reports
Comparison
Hospitals
Historical and
current financial
and utilization
reports, network
diagrams
2001
2002
2003
Current financial
and utilization
reports,
changes to
network
diagrams, EMS
documentation,
monitoring
reports
Current financial
and utilization
reports,
changes to
network
diagrams
Current financial
and utilization
reports,
changes to
network
diagrams, EMS
documentation,
monitoring
reports
Current financial
and utilization
reports,
changes to
network
diagrams
Current financial
and utilization
reports,
changes to
network
diagrams, EMS
documentation,
monitoring
reports
Current financial
and utilization
reports,
changes to
network
diagrams
A key issue in the evaluation design is determining the standard to which CAHs
should be compared. Because no CAHs existed in Minnesota prior to the
introduction of the Flex Program, it is not possible to compare the case study CAHs
6
to other CAHs. Instead two different comparisons will be used. First, changes in the
performance of individual CAHs will be compared over time — before conversion
and following conversion (pre/post analysis). Second, a random sample of ten CAHeligible facilities was selected as comparison sites. To date, none of the comparison
hospitals has converted to CAH. If any comparison hospitals do convert to CAHs,
they will be removed from the comparison sample. At least five comparison sites
are expected to remain in the sample until the conclusion of the evaluation. Table
1.5 lists the comparisons to be made.
Table 1.5
Standards of Comparison
Evaluation Issue
Financial impact
Comparisons
CAHs to Sample of Small
Pre/Post CAH
Rural Hospitals
√
√
Changes in utilization
√
Physician integration
√
Physicians’ satisfaction
√
Quality of care
√
Changes in access
Changes in resident
satisfaction
Network development
√
EMS integration
√
√
√
√
√
√
Monitoring Reports
A baseline report collecting information on CAHs for the year prior to conversion will
be collected on all case study CAHs. Additionally, monitoring reports will be
collected annually from CAHs to assess ongoing changes in the staffing, network
arrangements, quality assurance, and the CAH’s ongoing satisfaction with the Flex
Program, as well as to report on the uses of grants received under the Flex
Program.
Site Visits, Telephone Interviews, and Targeted Surveys
Site visits have been conducted in the ten case-study CAH communities. The
purpose of the site visits is to interview the CAH administrator, to gather information
from other CAH staff, and to conduct community focus groups.
Interviews with CAH administrators focus on obtaining information about 1) the use
of grant money, 2) the conversion experience, 3) networking relationships and local
integration, 4) EMS plans, and 5) the CAH’s quality assurance program.
7
Information from physicians and non-physician providers on physician integration
and satisfaction with practice under the CAH model has been obtained through a
short written survey. The CAH administrator is asked to conduct the survey at the
first medical staff meeting following the initial site visit. The survey will be
administered a second time approximately 24 months later. Physician surveys may
be augmented by interviews with the local EMS medical director and either the
president of the medical staff, the hospital medical director, or the emergency room
medical director of the hospital to which the CAH primarily refers.
In lieu of community surveys of access to and satisfaction with the CAH model,
focus groups have been conducted in case-study communities. The focus groups
have been composed of up to ten participants. To obtain a cross-section of opinion
in the community, case-study participants were drawn from a variety of organizations
and possess a variety of characteristics. CAH administrators in the case-study
communities selected the focus -group participants, based on input about the cross
section of community members and characteristics.
Data from all sources (both primary and secondary) for case study facilities have
been summarized for analysis. Appropriate comparisons of the characteristics of
case study CAHs and the effect they have had on the community will be made. Site
visits were conducted following conversion and will be followed up approximately 24
months after the initial visit.
Financial and Other Secondary Data
Secondary data for the evaluation is derived from a variety of sources including
Medicare cost reports, audited facility financial statements, Health Care Cost
Information System reports, documentation of activities of EMS agencies (i.e., EMS
Regulatory Board, regional EMS Coordinating Boards, and local EMS agencies),
MDH Facility and Provider Compliance Division licensure/certification surveys,
documentation of CAH quality studies performed by Stratis Health and the Medicaid
agency, and internal documents of case study CAHs.
A table summarizing all components of the evaluation and the data used may be
found in Appendix A.
8
CHAPTER 2
IMPLEMENTATION OF THE MEDICARE
RURAL HOSPITAL FLEXIBILITY PROGRAM
This component of the evaluation focuses on the accountability of the Minnesota
ORHPC for activities related to the Flex Program. It assesses the use of grant funds
and the activities undertaken by ORHPC to continue the program implementation in
Year 2.
In 1999, the Minnesota ORHPC obtained a $200,000 start-up grant from the federal
Office of Rural Health Policy (May 1999) and a first year implementation grant of
$550,138 (September 1999). For Year 2, ORHPC received a grant of $720,000
(September 2000). This grant was used for further development of Minnesota’s Rural
Health Plan, assistance with additional CAH conversions, enhanced networking
activities, improvement of emergency medical services, and improved quality of care.
Three grant programs totaling $506,000 were available to Minnesota communities
because of this award. The 2001 CAH Planning and Conversion grant program, the
2001 Minnesota Rural Flex Grant program, and the 2001 Supplemental CAH Grant
program provided 44 awards to CAHs, other rural hospitals, rural networks, and rural
EMS organizations. These grants are designed to support rural hospitals in their
planning for and conversion to CAH and to strengthen the development of rural health
networks A summary of each of these grant programs follows.
Over the first several years of the Flex Program, ORHPC made the following grants:
•
12 grants (June 15, 1999 through June 30, 2000) totaling $120,000
•
25 grants (Jan 2000 through Dec 31, 2000) totaling $330,000
•
44 grants (Jan 2001 through Dec 31, 2001) totaling $506,000
A summary of the activities related to these grants through 2000 is included in the
Minnesota Rural Hospital Flexibility Program First Interim Report (December 2000).
This chapter will describe additional activities for 2001, including highlights from the
previous report as needed.
OFFICE OF RURAL HEALTH AND PRIMARY CARE IMPLEMENTATION ACTIVITIES
(YEAR 2)
The Minnesota ORHPC engages in a number of activities in the implementation of the
Flex Program in the state. These include:
• Program support: monitoring changes in federal program legislation and rules
and communicating these changes to interested hospitals; convening and
staffing the Rural Hospital Flexibility Program Advisory Committee to obtain input
on program administration; designating CAHs and networks; meeting with Office
of Rural Health staff from other states to compare progress, collectively solve
9
implementation problems, and advocate for changes in the federal administration
of the program; preparing federal Office of Rural Health Policy grant applications
for subsequent year funding; updating the Minnesota Rural Health Plan as
needed; preparing proposed legislation for consideration by the Minnesota
legislature to implement needed changes in the state Flex Program; and
evaluating performance.
•
Grant making and grant administration: identifying fundable activities;
estimating the number of awards and the maximum amounts available; soliciting
grant applications; establishing grant review committees as needed; reviewing
proposals and making grant awards; processing grant payments; monitoring
progress; and receiving and reviewing final reports.
•
Technical assistance provision/program communications: conducting
preliminary financial feasibility studies; providing CAH application assistance;
conducting mock surveys; providing educational sessions; acting as the liaison
between communities and the federal Health Care Financing Administration (now
CMS) Regional Office, the Medicare fiscal intermediary, the Medicare Peer
Review organization, and state agencies; and preparing and mailing routine and
special CAH bulletins.
An estimate of the allocation of expenses over these three activities (based on the Flex
Program Grant awards) is as follows:
Table 2.1
Flex Program Expenses
Activity
Amount
Percent
506,000
69%
43,000
6%
Program evaluation
12,002
30,000
2%
4%
Indirect expenses (overhead)
118,998
19%
$720,000
100.00%
Grants to communities and hospitals
Technical assistance provision/ program communications
Program support and grant administration
TOTAL
Flex Program Support and Management
In the first year of the Flex program, the Rural Hospital Flexibility Program Advisory
Committee was established by ORHPC. The committee, composed of 31 members,
met 3 times during the first year and 3 times for planning the 2000-2001 year
(August 17, 2000; January 31, 2001; and April 17, 2001). In addition to staffing the
meetings, preparing background and research materials, reimbursing committee
10
expenses, and advising the chair, the ORHPC presented the following issues to the
committee during Year 2:
•
•
•
•
•
•
MN Rural Flex Funding in Action: examples of projects funded from the 2001
MN Rural Flex Grant (Regiona l Trauma System Development, Ambulance
Services Consortium Development, Community Health Information
Collaborative Telenetworking).
Reports and updates regarding CAH designation (which hospitals are
designated, which are in process, survey issues, staff/board education
concerns).
Grant awards announcements.
Reports from CAH representatives, Minnesota Emergency Medical Services
Regulatory Board (EMSRB), Minnesota Department of Human Services
(DHS), Noridian Government Services (Fiscal Intermediary), Stratis Health
(Peer Review Organization), and Minnesota Hospital and Healthcare
Partnership (MHHP).
Announcements/updates regarding regional/national meetings.
Announcements/updates regarding federal or state legislation affecting the
Flex program.
Discussion centered on changes to the necessary provider definition in state statute,
workforce issues and expansion of the loan forgiveness program (in the areas of
dental, pharmacy, and health care technician) quality assurance and quality
improvement initiatives, and EMS issues. With respect to workforce, the committee
addressed the acute need for health care workers in rural Minnesota and noted that
while loan forgiveness programs are helpful in getting professionals to rural areas,
that this doesn’t necessarily match existing vacancies. There is an on-going need to
address filling vacancies where they now exist or have been open for extended
periods of time. Positive feedback was expressed in the areas of quality assurance
and quality improvement, particularly around quality conference calls that have taken
place. Plans for future sharing of quality information among Flex program
participants was suggested by committee members and additional quality topics
were addressed. EMS and the potential impacts of changes in the fee schedule
were also discussed by the Flex committee. This included discussion of the impact
on seniors of the costs of ambulance services and the higher relative costs of
ambulance services in Minnesota compared with other states. Finally, the Flex
committee has also been involved in discussions around rural health profile
development and preparation for updating the Minnesota Rural Health Plan.
The ORHPC is the state agency responsible for designating CAHs. Through Year 2,
the ORHPC designated 16 CAHs. Of the sixteen designated by the ORHPC,
fourteen had been surveyed and approved by The Centers for Medicare and
Medicaid Services for participation in the program by August 31, 2001. The ORHPC
provided designated CAHs a variety of technical assistance services (see below).
During Year 2, ORHPC continued work on its ambitious multi-year evaluation plan,
which was designed to complement the work of national evaluators for this program
11
and to provide timely local information for improvement of program implementation
activities. Year 1 findings were reported in December, 2000. This report includes
findings through Year 2, and the evaluation activities will continue for two additional
years. As far as we are aware, Minnesota’s Flex Program e valuation is the most
ambitious of any state participating in the program, based on its complex multi-year
design.
ORHPC staff attended regional and national meetings to learn about and to discuss
Flex Program-related issues with national policymakers a nd with colleagues from
other state offices of rural health.
Finally, the ORHPC wrote an application to ORHP for Year 3 funding. Evidence of
the merit of Minnesota’s Year 3 Flex Program Implementation Plan is that Minnesota
once again received a large grant award to continue its work on the Flex program.
Grants to Hospitals and Communities
In the Minnesota Rural Health Plan (July 1998), the ORHPC identified the set of
hospitals eligible to apply for CAH certification. This list was modified in 1999 by the
Minnesota legislature when it revised the state’s definition of “necessary providers”
to include hospitals located in federally designated medically underserved areas and
health professional shortage areas. Eligible hospitals then fell into two groups:
those that met all of the federal requirements of certification and those that met
Minnesota’s definition of a “necessary provider of health care services” and other
federal requirements. That brought the number of eligible hospitals in Minnesota to
76. During the 2001 Minnesota legislative session, the legislature again modified
the language describing hospitals. The legislature changed the necessary provider
definition to include hospitals located in a county with a HPSA or MUA or located in
a county contiguous to a county with a HPSA or MUA. This change made all rural
hospitals in Minnesota geographically eligible for CAH designation. Approximately
80 hospitals are geographically eligible and are licensed for 50 or fewer beds. Of
those, it is estimated that approximately 65 are likely to become CAHs or explore
CAH designation.
Three grant programs were available in Year 2: the 2001 Critical Access Hospital
Planning and Conversion Grant, the 2001 Minnesota Rural Flex Grant, and the 2001
Supplemental Critical Access Hospital Grant. A total of 54 applications requesting
$787,352 were submitted to these grant programs. Forty-four grants totaling
$506,000 were awarded.
12
Table 2.2
Summary of Year 2 Grant Programs
Grant Program
2001 CAH
Planning &
Conversion Grant
2001 MN Rural
Flex Grant
2001
Supplemental CAH
Grant
Totals
Number of
Applicants
Total
Amount
Requested
Total Amount
Number of
Awarded in Grant
Awards
Program
22
$306,830
22
$225,000
16
$402,522
12
$235,000
16
$78,000
10
$46,000
54
$787,352
44
$506,000
Those applying for grants included 38 CAH-eligible hospitals, two EMS consortiums,
one hospital network, two hospital and clinic consortiums, one nursing home, and
one local public health agency.
The 2001 CAH Planning and Conversion Grant Summary
Application guidelines for the 2001 CAH Planning and Conversion Grant Program
were sent to each eligible hospital, made available on the ORHPC website, and
explained and distributed at the Grants Workshops. All hospitals submitting an
application received an award, but most award amounts were reduced from the
amount requested. The grant requests and awards are summarized as follows:
Average Amount Requested:
Average Award:
Award Range:
$13,900
$10,230
$7,500 - $15,000
Activities supported by this grant program included financial feasibility studies,
community education and needs assessments, hospital policy and procedure
development, staff education, and CAH application preparation. Twenty-two
hospitals received an award; several hospitals accomplished two or more objectives
(e.g. financial feasibility study, CAH application preparation) with one grant award,
for a total of 46 projects under this grant. The table below summarizes the projects
funded by this grant.
13
Table 2.3
2001 CAH Planning and Conversion Grant – Use of Grant
Funds
Use of Grant
Number of Projects
Financial feasibility studies
16
Community Forums/ Education
9
CAH Application preparation
9
Staff Education
6
Community needs assessments
6
Total Projects Funded
46
There has been a gradual shift in the grant programs from initial financial feasibility
study grants to CAH implementation project grants. This reflects the fact that many
hospitals have now completed their financial feasibility work and are moving on in
their activities toward conversion.
The 2001 Minnesota Rural Flex Grant Award Summary
Application guidelines for the 2001 Minnesota Rural Flex Program were sent to each
eligible hospital, made available on the ORHPC website, ORHPC monthly and
Critical Access News, and explained and distributed at the Grants Workshops. The
grant program was also announced in the State Register and the Minnesota
Department of Health Consolidated Grant Notice, as well as through the Emergency
Medical Services Regulatory Board (EMSRB) and the Minnesota Hospital and
Healthcare Partnership (MHHP).
Applicants eligible for this grant program consist of rural hospitals with 50 or fewer
beds, CAHs, and rural health networks (including EMS organizations). The grant
program funded activities that addressed the objectives of the overall Minnesota
Rural Hospital Flexibility Program.
Sixteen applications were submitted; twelve grants were awarded. The maximum
for any grant award was $25,000. The grant requests and awards are summarized
as follows:
Average Amount Requested:
Average Award:
Award Range:
$23,780
$19,580
$8,000 - $25,000
Projects funded by this grant addressed regionalization of health care services, the
development and enhancement of rural health networks, workforce training and
shortages, consumer and staff education, and emergency medical services issues.
Table 2.4 summarizes the projects funded through this grant program.
14
Table 2.4
2001 Minnesota Rural Flex Grant –Use of Grant Funds
Grantee: Houston County Public Health, Caledonia
Project: Emergency Medical Services workforce development
Award: $25,000
Houston County’s three ambulance services came together in a collaborative effort to address
recruitment, training, and retention of volunteer Emergency Medical Technicians in this
project. The ambulance services, along with Houston County Public Health, Houston County
Emergency Management, the Houston County Sheriff’s Department, and Gunderson
Lutheran, Inc., have jointly developed a plan for county-wide emergency training, combined
strategies for recruiting volunteers, held events in recognition and appreciation of existing
volunteers, and engaged employers in exploring options for increasing the availability of
daytime employees willing to take on-call EMS shifts. This was the first time emergency
response agencies throughout the county successfully collaborated.
Results of this successful project include:
• Increased EMS Volunteerism:
The Houston Community Ambulance Service
increased its volunteer roster from 9 to 18 crew members in one year.
• Joint training: Eleven EMS-related services (police, fire, Sheriff, ambulance) attended
joint training on Cold Water Rescue Awareness and Air Bag Safety. This was the first
time this type of training was made available in this county, and the first time all EMSrelated services attended training together. Agricultural Trauma training was also
made available for the first time. Thirty-six participants from Houston County and
neighboring counties in Wisconsin and Iowa attended.
• Communications enhancement: The combination of out-dated communications
equipment and the hilly terrain in this county caused great hardship in the area of
reliable communications. This grant award assisted in the purchase of pagers,
portable radios, and a channel base radio used in dispatching emergency messages.
Grantee: Tracy Area Medical Services
Project: Development of an ambulance services consortium
Award: $15,000
Tracy Area Medical Services, a CAH, leads efforts to consolidate ambulance services serving
seven small communities in this project. Project activities include: hiring a shared Medical
Director, developing standardized protocols, developing a training curriculum, group
purchasing, and creating a centralized billing system.
Ambulance services in this area are extremely vulnerable financially and report difficulty in
recruiting and retaining volunteer EMTs. The consolidation of these services strengthens the
pre-hospital care available in the region, provides training and staffing enhancements that
help crews maintain adequate numbers of volunteers, creates options for group purchasing
resulting in significant savings, and maximizes reimbursement possibilities through centralized
billing.
15
Grantee: Rose au Area Hospital
Project: Expansion of diabetes center and education
Award: $21,000
Roseau Area Hospital, a 25-bed rural hospital in Roseau County, has expanded its
Diabetes Center to include more comprehensive education and assistance to area patients
living with diabetes. Grant dollars made it possible for a part-time diabetes educator to
expand her training and knowledge, and provided the development and printing of
educational materials.
As a result of this project, the Diabetes Center has informed more area citizens about the
signs and risks of diabetes, offered more screenings, and has ultimately provided treatment
and education for residents who had unknowingly been living with the disease.
Grantee: Community Health Information Collaborative (CHIC), Northeast Minnesota
Project: Regional telepharmacy and teleradiology assessment
Award: $25,000
CHIC is a collaborative of hospitals, clinics, and public health services in an eleven county
region of northeastern Minnesota designed to plan and develop a shared information
network linking hospitals, medical clinics, academic health programs, public health agencies
and other appropriate organizations. The goal of this project was to assess the need and
operational and financial feasibility of implementing telepharmacy and teleradiology systems
within the network.
As a result of the assessment, an infrastructure was developed to pilot telepharmacy and
teleradiology services between Grand Rapids and Deer River (phase one), and between
International Falls and Bigfork (phase two).
The provision of telepharmacy and
teleradiology services in these communities will increase access to these services locally,
provide higher quality services in the community, and reduce the costs of pharmacy and
radiology services.
Grantee: Cook County North Shore Hospital, Grand Marais
Project: Recruitment, training, and retention of EMTs and trauma training for nurses
Award: $25,000
The Cook County North Shore Hospital is undertaking two projects with this grant award.
One is the development of a training program for the nursing staff that will provide intensive
training focused on critical care, trauma, and obstetrical patients. The other is a
collaborative project with Cook County Schools in developing and implementing a schoolbased EMT training program and offering it as part of the school’s curriculum.
Students enrolled in this program spend an hour every weekday at the hospital participating
in EMT and other healthcare training. This innovative approach is providing high school
students the necessary training to become EMTs and gives them an understanding of
health-related careers. Several students currently enrolled in this program report the
intention of furthering their education in health care and seeking employment in emergency
and/or rural settings.
16
Grantee: North Region Health Alliance, Northwest Minnesota
Project: Health Wellness/Prevention Program
Award: $15,000
The North Region Health Alliance (NRHA) is a provider cooperative consisting of nine
independent health care systems in northwestern Minnesota. The NRHA is actively involved
in the Health Care Purchasing Alliance development efforts in the same region of the state,
and proposed this project as a tool to assist the Health Care Purchasing Alliance’s efforts in
fully assessing and addressing community health needs.
An assessment tool and plan for gathering information and opinions from community
members has been developed.
Grantee: Immanuel St. Joseph’s Hospital and Gold Cross/Mayo Health Systems
Medical Transport, Mankato
Project: Development of a Regional Trauma System
Award: $20,000
This project formed a collaboration of rural health care providers in a nine-county area in
south central Minnesota with the goal of developing a rural trauma system. The project is
currently underway. Thus far, ambulance Medical Directors and Managers have participated
in a regional retreat to learn about the differences in pre-hospital care delivery within the
region, the experience of other trauma system development projects, available county, state,
and national resources, and to develop a more detailed work plan.
Grantee: Murray County Memorial Hospital, Slayton
Project: Comprehensive Needs Assessment for Collaboration between 3 Rural
Hospitals
Award: $17,000
The hospitals in Slayton, Westbrook, and Tracy (each is a Critical Access Hospital) are
exploring opportunities to collaborate and possibly consolidate certain services.
Approximately 600 residents in the combined market areas for the three hospitals were
surveyed in order to confirm which services were needed and wanted in each area, and
whether consolidation of some services and administration functions was feasible. Initial
results include the combined billing and leadership of the three facilities.
Grantee: Lakewood Health Center, Baudette
Project: 1) Development of a physician recruitment and retention program and 2)
Analysis of appropriateness of establishing a provider-based Rural Health Clinic
Award: $25,000
Lakewood Health Center contracted with the Minnesota Center for Rural Health for the
development of a detailed physician recruitment and retention plan. In addition, the CAH and
the clinic, as part of the ongoing integration of the two organizations, contracted with
consultants to thoroughly analyze the organizational composition of the facilities and the
appropriateness of establishing a provider-based Rural Health Clinic.
As a result of the grant, the physician recruitment and retention plan has been fully
implemented. Also, the clinic and CAH continue to assess integration feasibility, and
establishment of a provider-based Rural Health Clinic is likely.
17
Grantee: Lac qui Parle Health Network
Project: Group purchase of ultra sound equipment
Award: $25,000
Lac qui Parle Health Network is a non-profit management service organization comprised of
five rural hospital systems. In an effort to continue integration of the member hospitals and
improve patient access to quality services, Lac qui Parle Health Network developed a plan to
purchase and coordinate the shared use of diagnostic ultra sound equipment.
The portable ultra sound equipment is used mainly in the emergency room of each facility,
and is moved from facility to facility on a weekly basis. Physicians at each of the hospitals
have been trained and credentialed on the use of the new testing equipment. Each facility
has reported increased utilization of ultra sound testing since implementation.
Grantee: Mahnomen Health Center
Project: Workforce Enhancement and Training
Award: $14,000
Mahnomen Health Center (a CAH) identified workforce retention as problematic in part due to
the lack of educational and training opportunities for staff. With this award, an assessment
was conducted, and a managerial team-building program was implemented.
Ongoing
continuing education workshops are occurring, workplace safety educational programs have
been conducted, and a library of “Training Network” videos (such as “Don’t Shoot the
Messenger”, “From Stress to Success”) has been established.
Grantee: Greater Northwest Emergency Medical Services
Project: Critical Incidence Stress Management Training and Awareness
Award: $ 8,000
Greater Northwest Emergency Medical Services and neighboring West Central Emergency
Medical Services are regional EMS planning agencies serving First Responders, Ambulance
Services, Hospitals, and other emergency support services (e.g. Fire, Law Enforcement) in a
total of 21 rural Minnesota counties.
With this grant award, Critical Incident Stress Management teams (comprised of peers and
mental health professionals) were created to provide education, counseling, and diffusion of
post-traumatic stress experienced by emergency response volunteers.
The 2001 Supplemental CAH Grant Summary
Near the end of Year 2, it was determi ned that additional federal Flex program
dollars were available through the ORHPC for CAH-related activities. As a result,
the 2001 Supplemental CAH Grant program was announced and made available to
all CAHs and CAH-eligible hospitals. This grant program offered grants of up to
$5,000 for activities associated with assessing the operational or financial feasibility
of CAH conversion, the conversion process, or operations as a CAH.
Sixteen hospitals applied for funding; ten awards were granted. The application
requests and awards are summarized as follows:
Average Amount Requested:
Average Award:
Award Range:
$4,870
$4,600
$3,000 - $5,000
The table below summarizes the projects funded by this grant.
18
Table 2.5
2001 Supplemental CAH Grant – Use of Grant Funds
Use of Grant
Number of Projects
Financial feasibility studies
8
CAH Application preparation
2
Total Projects Funded
10
As was shown in the tables above, a number of grants were used by hospitals to
look at the financial feasibility of conversion to CAH or to prepare their applications
for CAH designation. When CAH administrators of hospitals that converted in Year
2 were asked about the role of these grants, several expressed the importance of
the grant in helping to make the conversion decision. As one administrator stated it,
“the grant money was extremely critical” to the assessment of CAH and actual
conversion. It was “important to be able to quantify the data” in order to make a
decision. Another described the grant as “critical because if the knowledge we
gained through our analysis (paid for by the grant) had not been available, it (CAH
conversion) would not have happened. We didn’t have the resources and
knowledge to convert otherwise.” Finally, a third administrator stated that the grant
was needed “to develop decision criteria.” Without these, the decision about
conversion, based on the data, could not have been made.
Table 2.6 below shows a summary of the grants by hospital that were made during
Year 2.
19
Table 2.6
Summary of Grants to Rural Hospitals and Communities
2001
2001
CAH
2001
CAH Total Year
Hospital/ Organization
City
P&C
Flex Suppl. 2 Awards
1 Bridges Medical Center
Ada
2 Riverwood Health Care
Aitkin
3 Albany Area Hospital
Albany
4 Appleton Municipal Hospital
Appleton
5 Arlington Muncipal Hospital
Arlington
$7,500
$7,500
6 White Community Hospital
Aurora
$10,000
$10,000
7 Clearwater Health Services
Bagley
8 Lakewood Health Center
Baudette
$25,000
$25,000
9 Greater Northwest EMS
Bemidji
$8,000
$8,000
10 Swift-County Benson Hospital
Benson
11 Northern Itasca Health Care Center Big Fork
12 United Hospital District
Blue Earth
13 Houston County Public Health
Caledonia
$25,000
$25,000
14 Cambridge Medical Center
Cambridge
15 Canby Community Health Services Canby
16 Cannon Falls Community Hospital
Cannon Falls
$5,000
$5,000
17 Cass Lake Indian Health Services
Cass Lake
$12,000
$12,000
18 Community Memorial Hospital
Cloquet
$12,000
$12,000
19 Cook Hospital
Cook
20 North Region Health Alliance
Crookston
$15,000
$15,000
21 Riverview Hospital
Crookston
22 Cuyuna Regional Medical Center
Crosby
23 Lac qui Parle Health Network
Dawson
$25,000
$25,000
24 Johnson Memorial
Dawson
$10,000
$10,000
25 Deer River Health Care Center
Deer River
26 Comm. Health Info. Collaborative
Duluth
$25,000
$25,000
27 Ely-Bloomenson Community Hospital Ely
$3,000
$3,000
28 First Care Medical Services
Fosston
29 Glencoe Area Health Center
Glencoe
$5,000
$5,000
30 Glacial Ridge Hospital
Glenwood
31 Graceville Health Center
Graceville
$10,000
$10,000
32 Cook County North Shore Hospital Grand Marais
$25,000
$25,000
33 Granite Falls Municipal Hospital
Granite Falls
34 Kittson Memorial Hospital
Hallock
35 Hendricks Community Hospital
Hendricks
$5,000
$5,000
36 Falls Memorial Hospital
International Falls $8,600
$8,600
37 Divine Providence Health Center
Ivanhoe
38 Jackson Medical Center
Jackson
$9,500
$9,500
39 Lake City Medical Center
Lake City
$5,000
$5,000
40 Minnesota Valley Health Center
LeSueur
$8,900
$8,900
41 Long Prairie Memorial Hospital
Long Prairie
$9,500
$9,500
42 Luverne Community Hospital
Luverne
20
Table 2.6 Continued
Hospital/ Organization
City
43 Madelia Community Hospital
Madelia
44 Madison Hospital
Madison
45 Mahnomen Health Center
Mahnomen
46 Immanuel St. Joseph's/Gold Cross Mankato
47 Melrose Area Hospital
Melrose
48 Chippewa-Montevideo Hospital
Montevideo
49 Mercy Hospital & Health Care Center Moose Lake
50 Renville County Hospital
Olivia
51 Mille Lacs Health System
Onamia
52 Ortonville Municipal Hospital
Ortonville
53 Pipestone County Medical Hospital Pipestone
54 Red Lake Indian Health Services
Red Lake
55 Redwood Falls Municipal Hospital
Redwood Falls
56 Roseau Area Hospital
Roseau
57 Pine Medical Center
Sandstone
58 Murray County Memorial
Slayton
59 Sleepy Eye Municipal Hospital
Sleepy Eye
60 St. James Health Services
St. James
61 St. Peter Community Hospital
St. Peter
62 Lakewood Health System
Staples
63 Minnewaska District Hospital
Starbuck
64 Tracy Municipal Hospital
Tracy
65 Lakeview Memorial Hospital
Two Harbors
66 St. Elizabeth's
Wabasha
67 North Valley Health Center
Warren
68 Waseca Area Medical Center
Waseca
69 Westbrook Health Center
Westbrook
70 Wheaton Community Hospital
Wheaton
71 Windom Area Hospital
Windom
72 Zumbrota Health Care
Zumbrota
2001
CAH
P&C
$10,000
2001
Flex
2001
CAH Total Year
Suppl. 2 Awards
$10,000
$15,000 $14,000
$20,000
$29,000
$20,000
$10,000
$9,500
$10,000
$9,500
$12,000
$12,000
$10,000 $21,000
$31,000
$12,000 $17,000
$5,000
$5,000
$29,000
$5,000
$5,000
$5,000
$5,000
$10,000
$25,000
$10000
$3000
$3000
$5000
$10000
$8500
$5000
$10,000
$10,000 $15,000
$10000
$10000
$8500
$225,000 $235,000 $46,000 $506,000
Totals
Technical Assistance and Communications
During Year 2, in addition to the program support and grant-related activities, the
ORHPC conducted several technical assistance and communications activities. Table
2.7 summarizes the technical assistance activities of the office.
21
Table 2.7
Year 2 ORHPC Technical Assistance Activities
Total
Contactsa
In-person
Contacts
Mock
Surveys
Year 2 CAH converts
1,020
10
7
Considering CAH/ Conversion
in process
1,020
22
7
20
0
0
2,060
32
10
Non-hospital organizations
Total
a
Contacts by telephone, e-mail, fax, and in person. Numbers are approximations.
The number of contacts with hospitals and non-hospital organizations provided by
the ORHPC rose dramatically from Year 1 to Year 2. During Year 1, contacts
totaled about 200. This rose to over 2000 during Year 2, reflecting the increased
knowledge about and interest in CAH designation by hospitals, the services provided
by the ORHPC in technical assistance visits and “mock surveys,” and many phone,
e-mail, and fax communications with these organizations.
A summary of the types of technical assistance activities provided by the ORHPC is
listed below:
•
•
•
•
•
•
•
•
Financial services
o Conducting preliminary financial feasibility study
Educational services
o Presenting CAH education sessions for hospital staff
o Preparing CAH education/information materials for use by hospital staff
o Presenting an overview of the Flex Program to community and/or hospital
governing board
o Preparing CAH education/information materials for use by community
and/or hospital governing board
CAH application assistance
o Designing network agreements
o Designing referral and transfer agreements
o Designing network communications agreements
o Designing emergency and non-emergency transfer agreements
o Designing credentialing and q uality assurance agreements
o Developing and establishing a professional practice review process
Developing and establishing an emergency services plan
Discussing and identifying what is needed to show community involvement in the
CAH decision-making process
Identifying information needed for a community needs assessment and
discussing how to collect it
Assisting with completion of HCFA form 1514
Survey preparation services
o Providing sample CAH policies and procedures
22
•
o Conducting a “mock survey” of the facility
Featured articles about CAH in each monthly issue of Office of Rural Health &
Primary Care Monthly Update and three out of four issues of Office of Rural
Health & Primary Care Quarterly. Critical Access News , an episodic publication
dedicated to the F lex Program, was established during Year 1. Two issues were
produced in each of the first two years of the program.
The MHHP, as noted earlier, provided technical assistance and communication
services in connection with the ORHPC.
•
•
•
•
•
Summary of Year 2 Findings
The ORHPC has continued to target hospitals that would most likely benefit from the
Flex Program. In partnership with the Minnesota Hospital and Healthcare
Partnership (MHHP), the office has engaged in numerous activities to make target
hospitals aware of the program and its possible benefits. This is demonstrated by
the increase in the number of hospitals that sought information about CAH
designation, grants for assistance in the conversion decision-making process, and
the increase in the number of hospitals that converted to CAH during Year 2 than in
Year 1.
The ORHPC effectively organized staff and other resources to implement the Flex
Program in Minnesota, focusing on program management, awarding grants, and
providing direct technical assistance to hospitals and communities.
The ORHPC awarded 44 grants to 38 CAH-eligible hospitals, two EMS consortia,
one hospital network, two hospital and clinic consortia, one nursing home, and one
local public health agency, financing 67 distinct projects. This work built on the
foundation of the 37 grants to 30 hospitals that were awarded in Year 1. Eight of the
hospitals receiving grants in Year 2 were certified as CAHs before the end of the
year. In addition, a number of hospitals receiving Year 2 grants had applied for
conversion before the end of Year 2 or shortly thereafter. The grants appear to have
played a key role in the decision to convert and planning for conversion. Interviews
with administrators from the Year 2 CAHs confirmed this, with descriptions of the
role of the grants as “critical” and “extremely critical” in establishing decision criteria,
gathering relevant data, and making the conversion decision.
Grants made to hospitals and communities in Year 2 focused primarily on
conversion assessment and planning, community needs assessment, development
and enhancement of rural health networks, staff and community education, and a
number of specific projects in the areas of EMS, telemedicine, wellness, and trauma
system development.
The ORHPC provided a wide variety of communication and technical assistance
services to eligible hospitals. There appears to be a relationship between
conversion and the amount of technical assistance provided by the ORHPC. This
relationship suggests that support from the ORHPC increases immediately before
and after conversion. Administrators from the hospitals that converted during Year 2
all rated the assistance provided by the ORHPC as 9-10 (on a scale of 1 to 10, with
10 being very helpful). Assistance included clarification of regulations, survey
guidelines, immediate information and resources, and information such as that
provided in the ORHPC Critical Access News publication. One administrator said
23
the staff of “ORHPC were the teachers and we were the students out here who
wanted to learn. “ Another administrator noted that he regretted not using the
available services because he felt that the process would have gone “a lot more
smoothly.”
24
Chapter 3
PHYSICIAN INTEGRATION AND SATISFACTION
Physician (and non-physician provider) integration into CAHs through employment
creates a potential benefit for a CAH community. There are two primary reasons for
formally integrating providers into a CAH. The first reason concerns recruitment and
retention of providers. Making a provider an employee of the CAH assures the provider
a level of pay and benefits that might otherwise be unattainable in many small rural
communities. The stability of pay and benefits also encourages retention. The second
reason concerns what is often referred to as the “alignment of incentives” between the
medical staff and the hospital. Payment systems often produce inconsistent behavior
between hospitals and their medical staffs. For example, hospitals and physicians may
compete with one another over outpatient laboratory, EKG, or radiology services.
Physicians may believe they have an incentive to produce more services for patients,
because payment is linked to individual units of service. Some physicians are reluctant
to provide pro bono services to the hospital under the terms of their medical staff bylaws
(e.g., committee membership and emergency room coverage). Employing providers
removes many of these issues by relieving physicians of many of their financial
concerns.
The evaluation measured changes in the employment of physicians’ pre- and postconversion to CAH. Through a medical staff survey, the providers at CAHs were asked
whether they had been informed and whether they approved of the conversion to CAH.
They were also asked to rate their expectations of the benefits of conversion for the
hospital, the community, and their own practice. Finally, the practitioners were asked a
set of questions related to their satisfaction with CAH practice.
In the hospitals that converted to CAH during Year 1 (n = 2), neither employed the
physicians. One hospital provided office space to the practitioners and the other had a
management agreement with an urban-based integrated delivery system that staffed
the adjacent rural health clinic. This type of management agreement integrated the
physicians into the hospital environment.
Among the eight hospitals that converted to CAH during Year 2, slightly more than one third (34.9%) employed the physicians or mid-level practitioners while the other twothirds did not. The hospitals provide office space to about one-fifth (20.9%) of the
practitioners. Additionally, many of the practitioners (65.1%) have offices on land
owned by the hospital or adjacent to the hospital, which is much different than the Year
1 CAHs. These factors indicate that the integration of practitioners through employment
by the hospital is greater for the Year 2 CAHs than for the Year 1 CAHs.
The picture of information shared with physicians regarding the conversion to CAH and
their level of support for the conversion are considerably different from that of the Year 1
CAHs. At the Year 1 CAHs, every practitioner was fully informed and supported the
conversion; this was not true or the Year 2 CAHs. This variation might be due to the
fact that the CAH program was new when the first two hospitals converted. This may
25
have brought more attention to the process and its benefits for the hospital and
community. Later hospitals had the benefit of learning from the Year 1 CAHs
experiences. In addition, since more physicians and mid-level practitioners were
involved with the eight CAH communities (43 versus 5) it should be expected that there
would be greater variance in their level of knowledge and support. In the Year 2 CAH, a
greater majority of practitioners (67.4%) felt that they were fully informed about
conversion before it occurred. An additional 18.6% felt that they were informed, but
would have liked more information about conversion. Several practitioners reported that
the conversion to CAH occurred before they were a part of the medical staff, and three
practitioners felt that information was not adequately shared with them regarding the
conversion process.
In terms of practitioner support for the conversion to CAH status, two-thirds of the
respondents fully supported the conversion. Fifteen percent said it didn’t matter to
them, and one practitioner was supportive, but didn’t think it mattered to them one way
or the other. Only two physicians reported that they were opposed to conversion, while
four others were not on the staff at the time of the conversion.
With respect to practitioners relationships with other medical staff members, over ninety
percent reported no change in their relationships since conversion to a CAH. Of the
three staff that felt that there had been changes following conversion, one stated that
the change had “promoted staff availability.” Another staff member felt that there was a
change in how “MD’s were now providing continuous care and admitting patients to their
hospital as opposed to elsewhere.” With respect to their practice, two-thirds felt that it
had stayed the same, while an additional nine percent reported an increase in their
practice since CAH designation. Only one provider felt that their office visits had
decreased since the change in licensing.
The medical staff were also asked to share their expectations regarding the benefits to
the hospital, community and their practices of converting to a CAH. As second
evaluation visits occur, staff will be asked if the actual performance corresponded with
their expectations. The results of the survey of expectations may be found on Table
3.1.
26
Table 3.1
CAH Providers Expected Benefits of Conversion (n=43)
No
Benefit
(1)
Benefits to hospital
Improve Medicare reimbursement
Improve overall financial position
Help retain/recruit physicians
Help recruit/retain MLPs
Less stringent regulations
Improved image in community because of
network linkages
Help obtain more technical assistance from
network partners
Improve hospital quality assurance and
performance improvement programs due
to network linkages
Improve communication between your
medical staff and referring
Benefits to community
The hospital will remain open when it
otherwise might have closed
The hospital will be better able to meet
community health needs
Improved inpatient and outpatient services
for the services you continue to provide
Improved emergency transportation
system
Improved routine transportation
Better continuity of care when transfers or
referrals are required
Greater availability of outpatient satellite
services from network partners
Benefits to provider’s practice
My practice would see an increase
inpatients
I would be better able to use non-physician
providers to help in my Practice
Improved relationships with referral
physicians and hospitals
Improved emergency transportation
system
Greater availability of continuing education
programs
Greater availability of clinical
Consultants and visiting specialists
27
13
14
14
Some
Great
Average
Benefit Benefit
Score
(2)
(3)
Number of responses
17
18
2.51
15
21
2.57
9
7
1.79
9
6
1.72
14
5
1.73
13
12
8
1.85
10
17
7
1.91
12
14
10
1.94
18
10
5
1.61
Number of responses
3
12
13
2.36
4
18
14
2.26
9
14
12
2.09
17
14
4
1.63
16
15
3
1.62
17
11
5
1.64
17
10
7
1.71
Number of responses
17
9
5
1.61
13
9
2
1.54
14
13
3
1.63
12
15
2
1.66
14
14
10
1.50
11
14
6
1.84
Like the medical staff in the Year 1 CAHs, the practitioners in the Year 2 CAHs
expected that the community and the hospital would benefit from conversion more than
their own practices. This is reflected in a range of average scores on benefits of CAH
conversion to the hospital and community of from 1.61 to 2.57 for the hospital and 1.62
to 2.36 for the community, while the range of scores for benefits to the provider’s
practice range from 1.50 to 1.66. For the Year 1 CAH evaluation, the lowest average
score was 1.4, for the perceived benefit to the physician’s practice in the community.
However, in the Year 2 CAHs, physicians rated the perceived benefit to their practices
as an average score of 1.61, well within the middle range of the scores on the perceived
value to their practice. Therefore, practitioners in the Year 2 CAHs were more positive
in their expectations about benefits of conversion to their practices than were
practitioners in the Year 1 CAH. With respect to their practices in the community, while
60 percent saw no changes in the number of visits in their practices, 9.3% saw an
increase in patient visits. Only one practitioner noted a decrease in office visits since
the conversion. The results are almost identical for their hospital practices, with one
more provider citing a decline in their hospital practice.
For the hospital, almost half of physicians felt that improving the overall financial
position of the hospital was of great benefit. Nearly as many saw great benefit in
improving Medicare reimbursement, and 25% saw great benefit in the network linkages
for quality and performance improvements.
For the community, one-third of the physicians felt there was great benefit to converting
because the hospital would be better able to meet community needs. Great benefit was
also noted because conversion allo wed the hospital to remain open in the community.
It was also felt that there would be improvement to inpatient and outpatient services.
CAH medical staff members were asked to rate their satisfaction with the CAH’s
networking arrangements on a five-point Likert scale with 1 being “very dissatisfied” and
5 being “very satisfied.” These findings are described in Table 3.2. With respect to
these networking arrangements:
Satisfaction with networking arrangements for quality assurance
• Approximately 50% were somewhat or very satisfied,
• Approximately 30% percent were neutral,
• Less than 5% were somewhat dissatisfied,
• No one was very dissatisfied, and
• 14% didn’t know
Satisfaction with credentialing arrangements
• Slightly more than 40% were somewhat or very satisfied,
• More than 30% were neutral,
• Less than 5% were somewhat dissatisfied,
• None were very dissatisfied, and
• 14% didn’t know
28
Satisfaction with for referral and transfer arrangements
• Slightly more than 40% were somewhat or very satisfied,
• 28% neutral,
• One person was slightly above neutral, but not quite somewhat satisfied.
• No one was very dissatisfied, and
• 16% percent didn’t know.
Table 3.2
CAH Provider Satisfaction
Very
Somewhat
Dissatisfied Dissatisfied
(1)
(2)
Satisfaction with networking arrangements…
Quality
2
Assurance
Credentialing
2
Referrals &
2
Transfers
Overall satisfaction with…..
The Hospital
3
Your primary
2
referral hospital
Your practice in
1
your community
Somewhat Very
Average
Neutral Satisfied
Satisfied Score
(3)
(4)
(5)
12
11
9
3.79
14
7
11
3.79
12
9
10
3.8
1
5
12
20
4.09
1
6
21
9
3.87
1
7
8
23
4.26
CAH medical staff members were also asked their level of satisfaction with the hospital,
the primary referral hospital, and their practices in the community. One respondent was
very dissatisfied with all of these. An additional respondent was very dissatisfied with
the primary referral hospital. But, for the most part, the staff members were quite
satisfied on these three dimensions. Results show:
Satisfaction with the hospital
• About 75% were somewhat or very satisfied,
• About 12% were neutral, and
• 9.3% were somewhat or very dissatisfied with the hospital (all of the dissatisfied
practitioners were at the same hospital except one).
Satisfaction with the primary referral hospital
• About 70% were somewhat or very satisfied,
• 7% were somewhat or very dissatisfied (two of these were the same practitioners
who were dissatisfied with the CAH).
29
Satisfaction with their practices in the community
• About 72% were somewhat or very satisfied,
• About 16% were neutral, and
• About 5% were somewhat or very dissatisfied with their practices in the community
(these medical staff were also dissatisfied with the CAH and referral hospital).
Overall, nearly three- fourths of medical practitioners were satisfied or very satisfied with
the hospital, the primary referral hospital and their practice in the community.
Summary of Year 2 Findings
• Of the Year 2 CAHs, more than one-third employed their medical staff and two -thirds
had offices on land owned by or adjacent to the hospital. This is a much higher
proportion of employment of medical staff members by the CAH and a higher
proportion with offices adjacent to the hospital leading to staff integration into the
CAH than Year 1 CAHs.
• Over two-thirds of the medical staff at Year 2 CAHs felt fully informed about
conversion, 19% felt informed but would have liked more information, and only 7%
felt that information was not adequately shared. Given the much higher number of
practitioners in the Year 2 CAHs than Year 1, the number of staff who felt fully
informed about CAH conversion continues to remain high. Similarly, a high
proportion of CAH staff fully supported conversion, with only 2.3% being opposed.
• As in Year 1 CAHs, Year 2 CAH medical staff members expected that the
conversion would benefit the hospital and community more than their own practices.
However, unlike staff at Year 1 CAHs, more of the staff at Year 2 CAHs expected
some benefit to their practices, and 9.3% reported an increase in their practices.
• Overall, the vast majority of CAH medical staff was satisfied with the hospital, the
primary referral hospital, and their practices in the community. There was less
satisfaction with the quality assurance networking arrangements with other facilities
(about 50%) and somewhat less satisfaction (about 40%) for credentialing and
patient referral and transfer.
30
CHAPTER 4
QUALITY OF CARE
The quality of services provided in CAHs is among the most frequently voiced concerns
of policymakers, practitioners, and the public at large. Hospitals that are small and
produce small volumes of service, that do not offer the complete range of services
offered by other hospitals, and that allow the use of non-physician providers to deliver
inpatient services, may be perceived as providers of low quality care. Perception of the
quality of care delivered in CAHs is as important as the reality: local residents may
avoid seeking services in CAHs if they believe that CAHs provide poor quality care.
Therefore, it is important to measure the impact of conversion on the quality of care
delivered in these facilities and to make the results known to local residents.
CERTIFICATION SURVEY ANALYSIS
One of the fundamental structural measures of quality is the ability of hospitals to be
certified as CAHs on their initial survey. As was the case with the CAHs that converted
during the first year, the Year 2 CAHs passed their initial surveys on their first attempt
and obtained certification from HCFA (now CMS). Like the Year 1 CAHs, all but one of
the Year 2 CAHs participated in the mock surveys conducted by the ORHPC and found
the visits to be very helpful for the actual survey. Only one Year 2 CAH did not take
advantage of the preparation help offered by the ORHPC.
After one year of operation, both Year 1CAHs had received their second survey from
the Minnesota Department of Health, Facility and Provider Compliance Division. Due to
budget constraints in the Facility and Provider Compliance Division, only three of the
Year 2 CAHs have received their annual re-certification surveys. These surveys took
place approximately one year after the hospitals were granted CAH designation.
Assistance in preparing for this second survey was offered by the ORHPC and was
utilized by two of the three facilities that were surveyed.
Unlike the initial survey that measured only the structural aspects of quality, the second
survey included the process and outcome measures. As might be expected, this more
extensive evaluation of quality produced more cited deficiencies. In the second survey
of the Year 1 CAHs, eight deficiencies were cited between the two hospitals. Of the
Year 2 CAHs, one was cited for deficiencies in their resurvey. Table 4.1 summarizes
the Year 2 CAHs deficiencies cited. (Note: Life Safety Code deficiencies are not noted
in detail on the table.)
31
Table 4.1
Analysis of Year 2 CAHs Survey Deficiencies
Second Survey
Regulatory Citation
Summary of Deficiency
The facility failed to include the Physician
Assistant or the Nurse Practitioner in the
development and the review of the CAH
policies.
The facility failed to have facility policies
PATIENT CARE POLICIES
developed with advice of the group of
professional personnel.
Source: Minnesota Department of Health, facility and Provider Compliance Division
485.631 (C) (1) PHYSICIAN ASSISTANT,
NURSE PRACTITIONER
Two survey deficiencies were cited among the three CAHs that received their
resurveys. One of the deficiencies concerned inclusion of mid-level practitioners in the
development and review of policies for the CAH. The expanded use of mid-level
practitioners under the Flex Program means that facilities must ensure that these staff
members are included in the policy development process. The second citation dealt
with including relevant parties in the policy development process. Both of these
deficiencies recognize the need for policy development to include all of the involved
parties, not to be developed without contact or communication with those who the
policies affect. As was noted in last year’s report, surveyors do not consider the
creation of these plans merely another regulatory hoop to jump through, but a blueprint
for action. This blueprint must be designed by and include representation of all of the
staff members.
COMPLIANCE WITH QUALITY ASSURANCE AND PERFORMANCE
IMPROVEMENT PLANS
CAH administrators were asked to provide examples of quality problems identified by
and addressed through their quality assurance/performance improvement systems.
The purpose of the exercise was to: (1) gauge the effectiveness of the problem
identification process at the CAHs and (2) assess the probable impact of the planned
intervention. Most of the Year 2 CAHs were able to provide such examples.
Some of the examples provided by Year 2 CAHs include:
• One CAH identified an increase in post-operative infections and formed a quality
committee that increased education for surgical personnel in respiratory therapy. In
addition, the respiratory therapist saw surgical patients on the day of surgery to
reduce the potential for post-operative infections.
• Another CAH was concerned about infections in expectant mothers, particularly
group B strep infections and how well these mothers-to-be were being monitored for
preventative antibiotics. A system was established to follow up on this issue from
the clinic to the hospital at the time the mother arrives for delivery.
• A security initiative identified lack of lighting, directional signage, and monitoring of
building entrances as factors leading to confusion by emergency room patients with
respect to accessing care. Actions taken involved improved lighting and signage, as
32
•
•
•
well as the addition of a security camera and patient call system. Patient satisfaction
is already improving as these steps are being implemented.
On patient surveys, one CAH found that patients were dissatisfied with food quality
and presentation; lacked information related to dietary education needs; and felt
there was a lack of food choices provided by the dietary department. As a result, the
CAH began purchasing higher quality products, upgraded steam-server equipment,
added tray garnishes and favors, purchased a water filtration system, increased the
use of dietary consultants, and developed pediatric “individualized menu planning.”
Patient surveys reflect that these changes resulted in an increase in patient
satisfaction.
A process improvement was initiated by one CAH when they identified billing
problems. The problems were related to holds for coding on charts, which was
slowing the payment process to the CAH. A consultant was hired to recommend
process improvements in coding and chart handling. Before the process
improvement initiative began, the involved department met its goal only 11% of the
time. By the second quarter, this had increased to 75%, and to 87.5% by the third
quarter.
Another process improvement activity at a CAH related to patient satisfaction and
their ease in understanding the billing statement. Actions included changes in
statements to improve the clarity for the patient. The actions resulted in a noticeable
reduction in patient billing complaints and a reduction by half in the accounts
receivable days.
Patient satisfaction is a widely accepted outcome measure of quality of care. Patient
satisfaction surveys for the CAHs and comparison hospitals were not obtained and
analyzed as part of this evaluation. However, CAHs are being encouraged to conduct
patient satisfaction surveys to aid in the assessment of quality. From the examples
given above, it is clear that CAHs are using patient satisfaction measures to address
quality issues.
As part of the ongoing evaluation process, the community focus groups conducted in
Year 1 and Year 2 offer a glimpse into patient satisfaction with the CAHs. The focus
groups consisted of community residents who used or whose family members had used
the CAH in the last year. These residents all rated the CAHs very highly. At four of the
eight Year 2 CAHs, all focus groups respondents were very satisfied with the quality of
care. At the other four CAH communities, the majority of focus group members were
very satisfied, with a few being satisfied. No one reported being dissatisfied with the
quality of care. One resident said that he had not used the hospital, so did not want to
rate the quality of care.
It should be noted that focus group members were selected from a suggested list by the
CAH administrators to participate in the meeting. Because of this, the focus group
members may not be representative of all patients and are may be somewhat biased in
favor of the CAH. It was clear, however, that in the Year 2 focus groups, there was a
much wider range of opinions about the CAHs than was observed in the two Year 1
CAH focus groups.
33
Summary of Year 2 Findings
• The eight CAHS seeking certification in Year 2 passed their initial surveys with no
difficulties. Seven of the CAHs made use of the mock surveys conducted by the
ORHPC.
• Of the eight Year 2 CAHs, only three received their re-certification survey after one
year. This was primarily due to budget constraints in the survey office. One of the 3
CAHs was cited for deficiencies, which were related to the role of mid-level
practitioners and inclusiveness in the policy development process.
• Most of the Year 2 CAHs submitted examples illustrating the facility’s quality
assurance program and its ability to identify problems, develop and implement
interventions, and measure results.
• The CAHs’ communities are vaguely aware of the change in licensing status of the
CAHs, and the communities highly rate the care provided by the CAHs. These
opinions may be considered indicators of quality.
• As with Year 1 CAHs, no significant problems with quality of care were identified a t
the Year 2 CAHs in the year following conversion.
34
CHAPTER 5
RESIDENT ACCESS AND SATISFACTION WITH CAHs
The impact of conversion to CAH designation on access to services and community
members’ satisfaction is difficult to measure. Several changes have taken place in the
Flex program, such as the change to a 96-hour annual average length of stay, during
the time that the CAH program is in the process of implementation. In future portions of
this multi-year evaluation, utilization data will be examined to discern trends. For this
report, in order to assess resident satisfaction with access and quality of care,
community focus group members were asked about these dimensions following the
conversion to a CAH.
Patient satisfaction with care is an indicator of quality. Residents’ satisfaction with the
CAH model – whether or not respondents actually used services – will help determine
community acceptance of conversion and help explain changes in inpatient and
outpatient utilization. Residents’ perceptions of the impact of CAH conversion on
access are included in their overall satisfaction with the model. Both patient satisfaction
and resident satisfaction were measured in community focus groups.
COMMUNITY FOCUS GROUPS
Community focus groups were held in all eight of the Year 2 CAH communities, with the
following number of residents in attendance:
Community C
Community D
Community E
Community F
Community G
Community H
Community I
Community J
7
5
5
6
5
7
9
6
(Note: Community A and Community B were described in the First Interim Evaluation
Report, December. 2000).
Focus group members were asked a series of questions regarding their use of the
hospital and their view of the importance of the hospita l to the community. The results
are described in Table 5.1 below.
35
Table 5.1
Community Focus Group Survey Results
Questions
Community:
C D E F G H I
They or a family member had been admitted to a hospital in
the last year
2 2 1 3 1 1 3 2
Had been admitted locally
2 2 0 3 1 0 1 0
Had used the outpatient services of this hospital in the last
year
How important is it to maintain the hospital in the
community? (Number rating it 5 - “very important”)
Total number of residents at the focus group
J
7 2 4 3 5 4 1 2
7 5 5 6 5 7 9 6
7 5 5 6 5 7 9 6
Most focus group members had not been admitted or had a family member admitted to
the hospital in the last year—either locally or elsewhere. A higher proportion had used
the outpatient services of the hospital in the last year, so could speak knowledgeably
about the quality of care they received. This knowledge will provide insights into
residents’ assessment of both quality of and access to care in their communities.
Residents were also asked how important it was to maintain a hospital in the
community. On a scale of 1 to 5, with 5 being “very important,” all residents rated it as
5. In the discussion, responses such as “the community is so thankful and appreciative
to have a hospital” were common among focus group members. In one focus group, a
member noted that their community was “fortunate to have had a culture that looked at
what was coming down the line” and planning for the future of the hospital in the
community.
Focus group members, many of who had used either the inpatient or, largely, outpatient
services of the hospital, were asked about their satisfaction with the quality of care
provided in the CAH. These residents were also asked about their satisfaction with
access to care. These ratings were given on a scale of 1 to 5, with 1 being “very
dissatisfied’ and 5 being “very satisfied.” The results are shown in Table 5.2.
36
Table 5.2
Resident Satisfaction with Quality and Access to Care in CAHs
(Number rating it as “very satisfied”)
Questions
Community:
C D E F G H I
Satisfaction with quality of care
7 5 5 5 4 7 7 3
Satisfaction with access to care
7 5 5 4 4 5
Total number of residents at the focus group
7 5 5 6 5 7 9 6
J
* 2
In terms of resident and patient satisfaction with quality of care at the CAH, the vast
majority of focus group members rated their satisfaction with a score of 5, “very
satisfied.” In Community G, one resident didn’t like to give perfect scores, so rated it a
4.5. Similarly, in Community I, one resident rated it 4.5 and one rated it 4, on the five
point scale. Community J had 3 residents who were “neutral” because they had not
used the hospital recently and did not want to give a rating.
In terms of satisfaction with access to care, the ratings also expressed high satisfaction.
One resident in community G rated it 4 on the five point scale because his wife had
expressed dissatisfaction with the lack of availability of a obstetric/gynecologic services
in the community. *None of the members of the Community I focus group wanted to
rate access to care. This community had been without a stable set of medical providers
for some time. However, they felt that the hospital was stabilizing and that new
physicians were now coming to the community –finally giving them a choice of medical
practitioners. They all wanted the situation described as “improving.” This situation will
be monitored over time as the evaluation continues and this community receives its
second site visit. Community J had concerns about access to health care services in
the community, due to the recent closure of the detoxification center in town. They also
expressed a desire for more health maintenance opportunities, and for upgraded EMS
from the basic life support system currently available. These were not directly related to
the hospital itself, but a reflection of recent changes and overall community needs.
A brief summary of each community focus group is presented in Appendix B and a
summary of overall common focus group themes is presented below.
Community focus group members were asked about the change to CAH designation,
how the community was informed, and the extent of community involvement in the
decision. As has been shown in earlier studies, the change in designation was
generally “invisible” to the community. Information about the possible change to CAH
was most commonly disseminated through:
•
•
•
Local newspapers or newsletter,
Presentations to civic groups and clubs,
Information contained in fund raising materials for the hospital, and/or
37
•
Calls to and discussions with key community leaders.
In terms of the community’s involvement in the decision to convert, most communities
saw this as a “hospital decision” rather than a broad-based community decision. In
several communities, residents stressed that community members had numerous
opportunities for input into the decision-making process, and these opportunities were
utilized to varying degrees by community residents.
Most community residents could not articulate the difference between a hospital and a
CAH. There was some knowledge expressed about differences in “fee payments” or
reimbursements to the hospital, and some residents knew that this would help their
hospital financially. Little was known about number of beds, average length of stay, or
other elements of CAH designation.
When asked if they would use the hospital tomorrow, if needed, the responses were
overwhelmingly positive. Most residents viewed the care at the hospital as being of
very high quality, and they would not hesitate to use the services. Residents in
response to this question gave descriptions of the services provided by the hospitals,
such as “caring and competent.” Respondents also mentioned network affiliations of
the hospital when discussing available care. In some communities, this perception
about their willingness to use the hospital has become more positive recently. In
Community F, residents used to see a “rent-a-doc” system at the hospital and felt that
there wasn’t continuity with physicians. In Community H, residents were less likely to
use the hospital because the insurance plans of the two major employers in the area
“won’t cover us” at the hospital. In Community I, people had not used the hospital (their
market share was recently 10-12%) because of the lack of stable physician practices in
the community over the past 15 years. The new administrator has done extensive
recruitment and a physician group now has established a clinic practice and makes
daily rounds at the hospital. Residents in this community were now more inclined to
seek care at the hospital because, as one resident put it, “I like what I see here.” (More
detailed descriptions from these community focus groups can be found in Appendix B).
In describing the quality of care at the CAH, respondents said they were “very confident
in the services” of the hospital. They felt that proper tests and care were available and
that appropriate decisions were made to transfer a patient if additional services were
needed. Almost all residents felt that their CAH provided high quality care. In
Community I, where medical care had been inconsistent in past years, those focus
group members who used the hospital were very pleased with the quality of care.
Several described their experience with the emergency department at the hospital as
“excellent.”
In terms of access to care, most of the focus group members said they were very
satisfied with access. A few were satisfied, but not very satisfied with the access to
care provided in the community. Reasons expressed for the less than total satisfaction
with access were that some services were not available at the CAH, such as cardiac
rehabilitation and other types of testing. Several respondents in different communities
were satisfied as opposed to very satisfied with access because of lack of a female
OB/GYN practitioner in the community.
38
CAH network affiliations were known to residents through the additional services that
these affiliations brought to the community. Visits from specialists, the diagnostic
“trucks” seen at the hospital, programs such as diabetes education, and transfers for
specialized care were all seen by residents as part of the hospitals’ networking.
Additionally, some community members knew that network affiliations reduced
duplication of paperwork, provided sharing of services, and included purchasing groups
that helped the hospital to save money on supplies and equipment.
Focus group members were also asked about what services were most important for a
hospital to provide. The most frequently cited services were:
•
•
•
•
•
•
•
•
•
•
•
ER
Lab and diagnostic services
Rehabilitation services, such as physical therapy and cardiac rehabilitation
Specialist appointments on a regular basis
Prevention and wellness programs, such as diabetes education or tobacco
cessation
General surgery
Home care and hospice
Consistent doctors and regular nursing care
Pharmacy
Obstetric services, if possible, to keep younger families in the community
Referrals for psychiatric and mental health care
Additional services mentioned by residents are found in the community focus group
descriptions.
Residents were also asked for their “wish list” of services that they would like to see in
their communities. These inc luded:
•
•
•
•
•
•
•
•
Obstetric and pediatrics
Mental health care
More types of surgery
Broader array of diagnostic testing and faster turnaround on labs
Wellness and prevention
Chemotherapy
Kidney dialysis
Urgent care
Finally, focus group members were asked about their concerns regarding the
conversion to CAH and future of their hospitals. One major concern was that funding
would change “mid-stream” and their hospitals would be back in the same position they
were in before conversion. Another pervasive concern was the ability of the hospital to
attract and retain physicians in the future. This means there must be jobs in the
community for spouses of the medical practitioners, good schools and compensation.
Many participants spoke about the importance of the hospita l in keeping families in the
community and ensuring that as farm families retire, that they move to their community,
39
as opposed to moving elsewhere. The role of the hospital, along with the school
system, in the community’s economic development was reiterated by many focus group
members as well. Several communities were looking forward to improvements in the
physical plant of their hospitals or the construction of new facilities. Construction and
improvements were underway at several CAHs, and focus group members were eager
to show off these improvements.
These focus group findings reiterate the importance of the local hospital to the
community. In some areas, such as the area described in Community E, loss of the
hospital would mean that no medical care would be available at certain times of the
year. This community frequently loses access to services due to annual spring flooding.
Residents are generally very positive about the care provided at their CAH and the
additional services available through network affiliations. They want to use doctors in
their community, both for convenience and for continuity of care. Many of the
community residents recognize improvements in physical plant and available services
that have taken place recently and look forward to making use of the improved services
in the future.
CAH MARKET SHARE
Use of CAHs by local residents relative to other alternatives is the ultimate test of
patient satisfaction with the CAHs and access to them. Patient destination (market
share) studies measure where patients from a specific market obtain inpatient health
services. CAHs that retain or increase market share are likely meeting the needs of
patients in terms of the range of services offered and the quality of services provided.
Use of local services may be considered a proxy for patient satisfaction, given that other
alternatives are available.
In Chapter 8, it is noted that utilization in the Year 2 CAHs, measured by average daily
census, rose slightly (.5) between 1999 and 2000, the year before conversion and the
year of conversion. Similarly, the average length of stay rose very slightly. This shows
improvement in numbers of patients using the CAH. However, while these hospital
statistics show small increases in patient use, they do not give a contextual picture of
the propensity of local consumers to use their community hospital as opposed to
choosing medical services elsewhere.
Table 5.3 presents market share information for several Year 2 CAHs (six of the eight
Year 2 CAHs reported patient origin data to the Minnesota Hospital and Healthcare
Partnership for both years).
40
Table 5.3
Market Share of Year 2 CAHs Before Conversion
And Year of Conversion (1999, 2000)
Hospital Admissions from CAH Primary Market
To All Other Rural
To All Urban
To CAH
Hospitals
Hospitals
Community C
Year before conversion
Number
Market share (%)
Year of conversion
Number
Market share (%)
412
53.8
295
38.5
59
7.7
432
50.7
346
40.6
74
8.7
372
57.5
147
22.7
128
19.8
287
46.5
184
29.8
146
23.7
749
45.0
436
26.2
481
28.9
783
43.9
502
28.2
497
27.9
482
29.9
742
46.0
390
24.2
529
29.6
842
47.1
416
23.3
143
10.6
564
41.9
638
47.4
189
12.7
659
44.3
640
43.0
Community E
Year before conversion
Number
Market share (%)
Year of conversion
Number
Market share (%)
Community F
Year before conversion
Number
Market share (%)
Year of conversion
Number
Market share (%)
Community G
Year before conversion
Number
Market share (%)
Year of conversion
Number
Market share (%)
Community I
Year before conversion
Number
Market share (%)
Year of conversion
Number
Market share (%)
Community J
Year before conversion
Number
268
17
Market share (%)
21.1
1.3
Year of conversion
Number
245
8
Market share (%)
18.9
.6
Source: Minnesota Hospital and Healthcare Partnership MHHP
Note: Due to rounding, total may not equal 100%.
Primary Market as defined by MHHP
41
985
77.6
1044
80.5
The picture of Year 2 CAH market share in the year before conversion and the year of
conversion is somewhat mixed. Generally, the CAHs show a slight decline in market
share, although most experienced an increase in the number of patients using the CAH.
But, there were increases in patients from CAH market areas seen at other rural
hospitals and at urban hospitals.
In Year 1, the CAH market share data showed an increase in patients, but loss of
market share to urban hospitals. For the Year 2 CAHs, the urban hospitals do not show
this pronounced gain in market share from CAH market areas, and in several, actually
show reduced market share (Communities F, G, and I). At the same time, there is an
increase in the market share of other rural hospitals. This may indicate that patients are
utilizing network partners of the CAHs.
Since there is considerable volatility in small rural markets with respect to hospital
utilization, data for the Year 2 CAHs in their year of conversion is probably inadequate
as a basis from which to draw conclusions. Generally, these data show a steady or
slightly increased market share for rural hospitals. The evaluation will continue to
examine data over time to monitor market share changes for CAHs and other rural
hospitals.
Summary of Year 2 Findings
• Year 2 CAH communities continue to be supportive of the conversion to a CAH. As
was the case with Year 1 CAHs, the actual “limitations” of the model (e.g., bed size,
average length of stay) are little noted by community residents. Instead, they view
the program as an expansion of the previously existing services, through networking
arrangements, greater availability of diagnostic testing and specialist appointments,
enhanced EMS, and improved reimbursement.
• Overall, the residents of the Year 2 communities had highly favorable opinions of the
quality of care provided and the access to services.
• Access was particularly important in communities such as Community E, who
frequently lose access to services due to annual spring flooding. Access was
especially important to Community I, which is just starting to see a stable physician
base after nearly 15 years of physician turnover (see Appendix B for Community
Focus Group summaries).
• Of the Year 2 CAHs for which data were available, the market share declined slightly
in the year of conversion, though an increase in the number of patients was seen.
There was not a pronounced use of urban hospitals as was seen in Year 1 CAHs,
but an increase in the use of other rural hospitals was noted. It is unclear at this
time if this change was related to the CAH network affiliations.
42
CHAPTER 6
NETWORK DEVELOPMENT
CAH designation requires establishment of one or more relationships with full-service,
acute care hospitals. The requirement is based on the assumption that the larger
facility will provide the CAH with clinical and administrative support. The support is
intended to improve quality and efficiency, which will help assure the local availability of
services. In some locations in Minnesota, CAH-like networking arrangements have
existed for many years. Designation will merely formalize these relationships. For other
hospitals, conversion to CAH may mean finding and establishing mutually beneficial
relationships with new partners.
In the first year evaluation, the two CAHs were a contrast in networking behavior. Prior
to conversion, one was not a member of any formal network or system, while the other
was a member of several networks, including a multi-hospital system, a hospitals-only
network, a regional cooperative, and a community network. With eight more CAHs
added to the mix, the Year 2 picture demonstrates a range of networking behavior.
To examine the changes over time in networking behavior, the CAHs were asked to
submit background information on their network relationships in the year before CAH
designation. Additionally, they were followed up a year after conversion to examine
changes in network relationships, including those that resulted from their planning for
and conversion to CAH.
Table 6.1
Networking Relationships of Hospitals Prior to CAH Designation
Year 2 CAHs
Type of Networking Relationship
Multi-hospital system
Purchasing alliance
National alliance
Hospitals-only network
Co-operative (defined by the State)
Telemedicine network
Community health network
Number
3
6
3
2
3
3
3
The number of Year 2 CAHs involved in network relationships before conversion in
shown in Table 6.1. Prior to designation as CAHs, several hospitals were involved in
networking relationships. The most common networking involved membership in a
purchasing alliance or buying group.
Hospital administrators of the Year 2 CAHs were asked specifically about their prior
relationships with their primary referral hospital. Administrators reported that prior to
conversion to CAH, six had informal relationships with the hospital to which it transfers
43
and/or refers patients, while two had formal relationships. As the result of CAH
certification, the following agreements were entered into by the CAHs with these
hospitals:
Table 6.2
Year 2 CAHs’ Networking with their Primary Referral Hospitals
(Agreements as part of the CAH certification process)
Type of Agreement
Patient referral and transfer
Communications
Credentialing
Quality assurance
Emergency transportation
Non-emergency transportation
Number of Agreements
7
6
4
4
4
2
In addition, five of the Year 2 CAHs entered into networking agreements with other
hospitals or agencies. The number of agreements Year 2 CAHs have in place is shown
in Table 6.3. For example, in the area of quality assurance, five Year 2 CAHs have one
formal agreement in place, while three have no formal agreements. In the area of
referral and transfer, one CAH has four separate formal agreements with other
hospitals, two CAHs each have 3 agreements in place, and one has two QA
agreements in place. Year 2 CAHs have a number of agreements in place around
referral and transfer and emergency transportation, with a variety of networking
partners. CAHs have fewer such agreements for QA, credentialing, and
communications.
Table 6.3
Year 2 CAHs Total Number of Networking Agreements
Type of Agreement
Referral and Transfer
Communications
Credentialing
Quality assurance
Emergency transportation
Non-emergency transportation
Number of Agreements
0 1 2 3 4 5
2 2 1 2 1 0
5 2 0 0 1 0
3 1 0 0 0 0
3 5 0 0 0 0
2 2 1 1 1 1
6 1 0 0 1 0
The CAHs are involved in many networking relationships, some of which are with their
primary referral hospital. But, they also have a range of networking agreements with
other facilities to meet their needs for credentialing, quality assurance, patient transport,
and so on.
In interviews with CAH administrators, changes in networking behavior before and
during conversion were discussed. The results are these discussions are presented
below.
44
In Community C, the administrator reported that the network agreements complemented
existing management relationships. The network infrastructure allowed services to be
brought to a smaller hospital, and the addition of one networking activity brought
behavioral health systems to the CAH.
Community D has always had networking relationships, and the administrator reported
they “are just using them more now.” This is particularly true in the areas of
credentialing and peer review. He felt that some of these things “were just the right
thing to do and would have happened regardless of CAH.” The CAH has agreements
for planning, joint purchasing, and clinical services, each under a separate agreement.
CAH conversion did provide assistance in adding home care as a service at this
hospital.
Community E always had an unwritten transfer agreement with their network hospital.
Since CAH, they have added chart review through this affiliation. There have been
some added costs for services such as peer review, which used to be provided. This
CAH does not have planning, joint purchasing, or clinical services agreements.
In Community F, there were previous networking relationships, but not for items like
credentialing. Their networking relationships have “been very positive” and the
administrator feels that everything they have tried has worked. They were previously
involved in a network for technical services, and this has remained the same before and
after CAH conversion. They are seeing increased consultative services now, with
specialists there “every day of the month.” The administrator feels that networking
helps them provide a “high level of services that they would not be able to do by
themselves.”
Community G belongs to a purchasing group, is in a planning co-operative, and now
receives QA services for several specialty groups at the hospital. The administrator
feels that the network hospital has been somewhat slow in reviewing and working on
their network agreement.
Community H had an existing relationship with its network hospital and the administrator
sees CAH-related networking as “just a natural extension” of what existed. Nothing has
really changed in their networking and they didn’t expect that it would. There has been
the addition of peer review for one group of practitioners. They have a pharmacy
agreement that assists with purchasing and pharmacy backup, but this has not changed
since CAH conversion.
In Community I, affiliations in two networks go back four years. For planning, the
hospital makes the plan with network participation and assistance. Their purchasing
group developed out of one of these affiliations. Finally, there has been financial
support throug h one of the affiliations, including support for physician recruitment,
credentialing, technical and regulatory issues, and information technology.
Finally, in Community J, the networking arrangements were not due to CAH but due to
the financial condition of the facility. The administrator said that “nothing has been a
surprise—the network hospital was supportive before and now.” The affiliation includes
45
some shared Board members, and help with things like information systems. They are
not currently doing joint purchasing, but this is being explored.
Overall, the networking relationships of the CAHs have been described in positive
terms. Many of these relationships existed prior to CAH designation, and were
continued or enhanced during conversion. Enhancements have occurred primarily in
areas such as credentialing, peer review, and quality assurance. Most CAH
administrators expressed satisfaction with these relationships, although some added
expense has evolved in particular areas.
Hospitals were asked to report on changes in their networking agreements in their
annual monitoring reports completed the year following conversion. For the most part,
there were no changes in the networking relationships in the year following conversion.
In one case, the network hospital was taken over by another health system. Otherwise,
no changes were reported in network relationships.
Summary of Year 2 Findings
• The Year 2 CAHs continued existing relationships with their primary referral
hospitals and in some cases these relationship were written into formal agreements.
• CAHs are involved in a number of agreements for patient transfer and referral,
clinical services, credentialing, quality assurance, purchasing, and emergency
transportation. Some CAHs are involved in multiple agreements in one or more of
these areas.
• The CAH administrators are primarily satisfied with the networking relationships.
Many of them expected few changes in these relationships after CAH designation.
Most of the changes were for additional enhancements. There were some additional
costs reported related to peer review.
• No changes were made in networking relationships in the first year after CAH
designation, suggesting that fundamental aspects of the relationship did not change.
• All eight Year 2 CAHs are integrated substantially by virtue of their diverse
networking relationships. This integration with full-service, acute care hospitals, as
well as other networking partners, helps to insure the local availability of services
and the quality and efficiency of such services.
• Based on the additional observations from the Year 2 CAHs, the Flex Program
appears to have resulted in little substantive change in networking behavior of rural
hospitals. The network relationships are more formali zed than before CAH
designation and some additional services have been added, but these seem to be a
continuation of networking activities that were in process before conversion.
46
CHAPTER 7
EMS DEVELOPMENT AND INTEGRATION
Integration of EMS services with CAHs is essential to assure quality of care and access
to services. CAHs are required by law to “make available” 24-hour emergency care
services. According to HCFA’s (now CMS) interpretive guidelines for CAHs:
This does not mean that the CAH must remain open 24-hours-a-day when it
does not have inpatients (including swing-bed patients). A CAH that does
not have inpatients may close (i.e., be unstaffed) provided that it has…a
system to ensure that a practitioner with training and experience i n
emergency care is on call and available by telephone 24-hours-a-day.
Because CAH emergency rooms may at times be closed and because personnel on-call
are allowed 30 minutes to respond (60 minutes in frontier areas – Cook, Lake,
Koochiching, Lake of the Woods, Kittson, and Marshall Counties), it is essential that
CAHs and EMS providers carefully coordinate their services. EMS providers must know
when the emergency room is closed.
CAHs in Minnesota are required to document in their application their pla nned hours of
operation (i.e., emergency room staffing) and their call plan for emergency services
when the CAH is closed. In addition, a transportation agreement that specifies the roles
of the CAH and one or more EMS providers must be in place.
All of the case study CAHs submitted EMS plans at the time of designation. The plans
displayed the following similarities and differences:
•
•
•
•
•
•
Only one of the Year 2 CAHs owns the local ambulance service. The other
seven CAHs are served by one or more local ambulance services, with a variety
of ownership structures (city, county, non-profit corporation).
The one CAH owned ambulance service has one paid staff person (2 hours per
day) and 14 volunteers. It is a basic life support (BLS) service.
The other CAHs are served primarily by BLS services, with air transport
agreements as well. At least one service has variances to carry additional
medications, such as epi pens and glucagon.
The ambulance services have mutual aid agreements with surrounding services.
All of the ERs at the eight Year 2 CAHs remained open 24 hours a day, seven
days a week. None of the CAHs plan to close their ER.
The EMS plans acknowledge the responsibility of CAHs to comply with all
COBRA/EMTALA requirements concerning treatment and transfer of ill or injured
patients.
The EMS plans of all of the case study CAHs satisfy the requirements of designation.
During the first year of operation, there were no material amendments to the EMS
plans.
47
The number of emergency room visits to the CAHs and the number of emergency room
and acute care transfers for the year prior to conversion and the year of conversion are
shown in Table 7.1.
Table 7.1
Comparison of Emergency Care and Transfers of Year 2 CAHs,
One Year Before Conversion and in the Year of Conversion
Year
Year of
Number Percentage
Before
Conversion Difference Difference
Conversion
ER Visits
Transfers
ER to another hospital
Transfers
Acute to another hospital
Number of days
ER was closed
14,304
14,282*
-22
- .15
1,119
1,108
-11
- .99
354
334
-20
-5.98
n/a
0
n/a
n/a
*It should be noted that one CAH added urgent care during the year following
conversion, and this substantially reduced their number of ER visits. Urgent care visits
are not included in the total. If this CAH is removed from the analysis, ER visits
increased 1443 for the other Year 2 CAHs, or 11.5%.
The overall number of ER visits changed very little for the Year 2 CAHs in the year after
conversion. The data are skewed by one CAH that added urgent care during the year
and then showed a drop in ER visits. When this CAH is removed from the analysis, ER
visits for the remaining Year 2 CAHs increased by a little more than eleven percent.
This is exactly in line with the growth in ER visits demonstrated by the Year 1 CAHs in
their year of conversion. Last year’s evaluation report hypothesized that conversion has
no effect on the use or availability of emergency room services. This hypothesis was
based on the notion that if local medical staffing improved as a result of conversion or
the public perception of quality improved due to networking relationships of the hospital,
then local residents may be more inclined to use the CAH emergency room. The
number of ER visits will be monitored for the remainder of the evaluation period to gain
a better understanding of what, if any, effect that CAH conversion might have had on
ER use.
The number of transfers from the Year 2 CAHs’ emergency rooms dropped by slightly
less than one percent in the year of conversion compared to the preceding year. The
Year 1 CAHs experienced an eighteen percent drop in ER transfers in their first year
after conversion. This indicator will also be tracked over time to look for patterns in and
explanations for changes in transfers from CAH emergency rooms.
The number of transfers from acute care beds at the Year 2 CAHs to referral hospitals
decreased by almost six percent in the year of conversion. This is in contrast to an
increase of twelve percent in acute care transfers in the Year 1 CAHs. However, for the
Year 1 CAHs, this represented only three additional transfers. This number will also be
48
monitored over time to look for trends in acute transfers. The extent to which the
change to a 96 hour annual average length-of-stay as opposed to a stricter 96 hour
maximum may have influenced acute care transfers is not known.
Overall, taking into account the addition of urgent care at one CAH, the Year 2 CAHs
showed an increase in the number of ER visits, no change in the number of ER
transfers, and a decrease in transfers from acute care beds. This reflects stability in
emergency services within the hospitals, prior to and following conversion to CAH.
CAH administrators and EMS Medical Directors were interviewed at each of the Year 2
CAHs regarding EMS planning. In addition, background information and CAH
applications were reviewed for information on EMS development and integration. This
research showed:
•
•
•
•
In contrast to the first year CAHs, only one of the Year 2 CAHs owns the
ambulance service. This is a Basic Life Support service with a paid staff member
2 hours per day plus 14 volunteers.
None of the first or second year CAHs plan to operate their Emergency Rooms
less than 24 hours a day.
All of the hospitals submitted EMS plans as part of their application process that
meet the requirements of designation as a CAH.
Hospitals report generally good relationships with local EMS providers and they
indicate that this has not changed since CAH designation. One CAH reports an
improved relationship with the local EMS provider since conversion.
In the first year of Flex Program grants to communities and hospitals, no grants were
made specifically or exclusively for EMS or EMS-related projects. Some of the 13 Flex
grants assisted with the preparation of CAH applications and undoubtedly dealt with the
compiling or formalization of EMS plans. In the second year, six grants totaling
$110,000 were awarded to CAHs, CAH-eligible hospitals, and rural ambulance services
for projects addressing recruitment and retention of EMS volunteers, training,
collaboration with other emergency services providers, and regional trauma system
development.
The CAHs participated in a pilot project of the Emergency Medical Services Regulatory
Board (EMSRB) during Year 1 of the Flex Program. EMSRB began planning for a
comprehensive Web-based quality assurance/outcomes data initiative in January 1999.
The dataset for the initiative mirrors that of the U. S. Department of Transportation’s
National Highway Traffic Safety Administration’s EMS Data Dictionary. This is the first
large-scale effort in Minnesota to collect out-of-hospital patient care and outcomes data.
The state’s CAHs are participating in the pilot program. The first two CAHs were
involved in planning the project. In addition, during the summer of 2000 equipment
necessary to implement data gathering was purchased for and installed in the CAHs by
EMSRB. Work is continuing on this project, with additional facilities being added to the
data collection activities over time.
49
Summary of Year 2 Findings
• The EMS plans of all eight Year 2 CAHs satisfy the requirements of designation.
None of the CAHs made significant amendments to their EMS Plans in the first year
of operation.
• In the year of conversion, the number of emergency room (ER) visits to the CAHs
grew by eleven percent (controlling for one CAH that added urgent care services).
This is consistent with ER changes seen in Year 1 CAHs. Emergency room
transfers remained almost unchanged, with less than a one percent reduction.
Finally, acute care transfers dropped by almost six percent, at this time it is unclear
what role the 96 hour annual average length-of-stay may play in this drop.
• Year 2 CAHs remain strongly integrated with EMS and report good relationships with
EMS providers. One CAH reported an improved relationship with the EMS provider
following conversion.
50
CHAPTER 8
FINANCIAL PERFORMANCE OF CAHs
An inherent goal of the Flex Program is to improve the financial position of small, rural
hospitals by paying CAHs for Medicare services on the basis of reasonable cost. Most
small rural hospitals are more dependent on Medicare than other hospitals. Nationally,
the rate of Medicare acute patient days to total acute patient days at rural hospitals with
49 or fewer beds was 63 percent in 1996; the rate for rural hospitals with 100 or more
beds was 56 percent (Rural Health Research Center, University of Minnesota, 1999).
Smaller rural hospitals also have the lowest profit margins of any hospital grouping,
urban or rural. One of the factors contributing to the poor financial performance of
small, rural hospitals is the Medicare Prospective Payment System (PPS).
PPS reimburses hospitals for the average cost of treating patients adjusted for the
diagnosis of the patient and the prevailing wages of the geographic area in which a
hospital is located. The average cost of treating a patient is composed of both variable
and fixed costs. Because small, low-volume hospitals have fewer units of service (i.e.,
admissions) over which to spread fixed costs, their per-admission fixed costs are often
greater than the amount implicitly accounted for in the PPS rate. As a result, the
hospitals are reimbursed by Medicare at a rate that is less than it costs them to provide
services.
Recognizing the flaws in prospective payment for small rural hospitals, the Flex
Program reimburses CAHs for the reasonable costs of services provided to Medicare
inpatients and outpatients. This change in payment methodology is i ntended to improve
the financial position of small, rural hospitals that convert to CAH status. The purpose
of this portion of the evaluation is to assess the impact of program participation on CAH
costs and revenues.
BASELINE COMPARISONS – 1999: THE YEAR BEFORE CONVERSION
In order to assess the financial impacts of conversion to CAH, two methods are
possible. One is to examine changes in financial condition pre- and post - conversion.
The second method is to examine CAH financial data compared with data from similar
“comparison hospitals” that have not converted to CAH. In the last evaluation report,
both of these comparisons were made using data from Medicare cost reports from the
Year 1 CAHs and ten comparison hospitals (see Chapter 1 on research methodology
and data). Changes in coding at the hospital level have delayed production of Medicare
cost reports, eliminating them as a data source for this report. In order to make some
comparisons, however, data from other sources have been utilized to provide basic
information regarding the financial performance of the Year 2 CAHs. Further analysis of
the first ten CAHs and the ten comparison hospitals will be included in the next
evaluation report, when more complete data are available.
Table 8.1 reports certain structural and operating characteristics of the CAHs that
converted in Year 2 and the comparison hospitals. Unlike the Year 1 CAHs, the Year 2
CAHs are slightly larger than the comparison hospitals in the year before conversion.
51
The CAHs had an average bed size of 28.75 in 1999 and the comparison hospitals had
an average bed size of 25.
The average daily census of the CAHs was less than that of the comparison hospitals,
3.4 patients compared to 4.2 patients. Despite the differences in a verage daily census,
the average lengths of stay were almost identical, 3.1 for the CAHs and 3.0 for the
comparison hospitals.
Looking at other characteristics of the Year 2 CAHs and comparison hospitals, the
CAHs’ total patient days averaged 1237 in the year prior to conversion while the
comparison hospitals averaged 1548 total patient days.
Table 8.1
Structural and Operating Characteristics of CAHs
And Comparison Hospitals, FY 1999 (The Year Before Conversion)
Bed Size
Average Daily Census
Average Length of Stay
Mean Total Patient Days
Critical Access
Hospitals
(n = 8)
Comparison
Hospitals
(n = 10)
28.8
25
3.4
4.2
3.1
3.0
1237
1548
Source: 1999 Health Care Cost Information System (HCCIS).
In the year before conversion, the Year 2 CAHs had lower patient days and lower
average daily census than the comparison hospitals, even though they had larger
capacity based on number of available beds. This may give an indication of why these
hospitals elected to pursue CAH designation at this time.
Table 8.2 shows the average of total operating expenses for Year 2 CAHs and the
average for the comparison hospitals, a reflection of the lower patient days and average
daily census shown in Table 8.1 above.
52
Table 8.2
Mean Operating Expenses of Year 2 CAHs
And Comparison Hospitals, FY 1999 (The Year Before Conversion)
Total Operating Expenses
Critical Access
Hospitals
(n = 8)
Comparison
Hospitals
(n = 10)
$3,804,193
$4,141,085
Difference in Average Expenses
$336,892
Source: 1999 Health Care Cost Information System (HCCIS).
In the year before conversion (FY 1999), the expenses of the CAHs totaled 8.86 percent
less than the comparison hospitals, or $336,892. This is partially a reflection of the
lower acute inpatient use rate of the CAHs. (Note: we are not able to further break this
down by expense type due to the lack of available data at this time.)
Mean revenues in 1999 of CAHs and comparison hospitals are displayed in Table 8.3.
The mean patient revenue of the comparison hospitals was 14.78 percent greater than
that of the CAHs, or approximately $535,000 per hospital. This is a reflection of the
lower patient days and average daily census shown in Table 8.1 (For Year 1 CAHs and
comparison hospitals, the difference in patient revenue was closer to twenty percent or
almost $875,000 per hospital in the year prior to conversion).
Other operating revenue is money earned by hospitals in the sale of goods and services
associated with hospital operations. Examples include cafeteria meals, copying of
medical records, and the sale of outdated equipment. In 1999, the year prior to
conversion, the mean amount of other operating revenue of comparison hospitals was
almost 16 percent (15.65) higher than that of the CAHs.
Non-operating revenue is income from sources not associated with the operation of the
hospital. It includes interest income, gifts, and tax money. The comparison hospitals,
on average, posted $13,359 (or 12.34 percent) more non-operating revenue than the
CAHs in the year before conversion.
53
Table 8.3
Mean Revenues of CAHs
And Comparison Hospitals FY 1999 (The Year Before Conversion)
Critical Access
Hospitals
(n = 8)
Comparison
Hospitals
(n = 10)
Total Net Patient Revenue
$3,619,327
$4,154,187
Other Operating Revenue
$143,489
$165,945
Non-operating Revenue
$108,249
Source: 1999 Health Care Cost Information System (HCCIS).
$121,608
While the differences shown here are not as large as those seen in comparing the Year
1 CAHs and the comparison hospitals (216.1% more operating revenue and 31.8%
more non-operating revenue), it is clear that those hospitals choosing to convert to CAH
designation experienced lower revenue than the comparison hospitals during the same
time period. This is reflected in patient revenue as well as other operating and nonoperating revenue.
FIRST-YEAR COMPARISONS
In looking at changes for Year 2 CAHs in the year of conversion, the analysis begins
with changes in structural and operating characteristics. Table 8.4 lists some of these
differences. Year 2 CAHs reduced bed size from 28.8 in the year prior to conversion to
15, in accordance with Flex program requirements. For comparison hospitals, bed size
remained almost constant (24.5 versus 25 in 1999).
Table 8.4
Characteristics and Utilization of Year 2 CAHs and Comparison Hospitals,
1999, The Year Prior to Conversion and 2000, the Year of Conversion
CAHs (n = 8)
2000 Difference
15.0
-13.5
3.9
.5
3.3
.2
Comp. Hospitals (n=10)
1999 2000 Difference
25.0 24.5
-.5
4.2
4.3
.1
3.0
2.8
-.2
1999
Bed Size
28.8
Average Daily Census
3.4
Average Length of Stay
3.1
Mean Total Patient
1237 1184
-53
1548 1523
Days
Source: 1999, 2000 Health Care Cost Information System (HCCIS).
-25
With respect to average daily census, the CAHs improved their daily census in the year
of conversion, from 3.4 to 3.9. Comparison hospitals stayed almost the same (4.2
compared to 4.3 average daily census). The average length of stay increased at the
Year 2 CAHs in the year of conversion from 3.1 to 3.3, while it decreased at the
comparison hospitals from 3.0 to 2.8 in the same year. As was shown in Chapter 7
54
(Table 7.1), CAHs experienced an increase in ER visits and a decline in both ER and
acute bed transfers in the year of conversion. By contrast, comparison hospitals
showed a slight decline in ER registrations from an average of 2054 to 2041 during this
period. Total patient days decreased at both the CAHs and the comparison hospitals
during this time period.
Operating expenses for the CAHs and comparison hospitals are shown in Table 8.5.
Table 8.5
Mean Expenses of Year 2 CAHs and Comparison Hospitals
1999 (The Year Before Conversion) and 2000 (The Year of Conversion)
Total Operating Expenses
1999
2000
Difference
Year 2 CAHs (n = 8 )
$3,804,193
$4,133,701
8.7%
Comparison Hospitals (n = 10)
$4,141,085 $4,532,579
9.5%
Source: 1999, 2000 Health Care Cost Information System (HCCIS).
Operating expenses at the Year 2 CAHs and the comparison hospitals both increased
during this time period. In the year of conversion, the CAHs reported 8.7% greater
operating expenses, while the comparison hospitals reported 9.5% greater operating
expenses. Again, more complete analysis of the first ten CAHs and comparison
hospitals will be provided in the Third Interim Evaluation Report, once Medicare Cost
Report data are available.
Table 8.6 shows patient revenues as well as operating and non-operating revenues of
the Year 2 CAHs and comparison hospitals.
55
Table 8.6
Mean Revenues of Year 2 CAHs and Comparison Hospitals
1999 (The Year Before Conversion) and 2000 (The Year of Conversion)
1999
2000
Difference
Total Net Patient Revenue
Year 2 CAHs (n = 8)
$3,619,327 $4,119,586
13.8%
Comparison Hospitals (n = 10)
$4,633,510 $4,154,187
11.5%
Other Operating Revenue
Year 2 CAHs (n = 8)
$143,489
$137,286*
-4.3%
Comparison Hospitals (n = 10)
$165,945
$171,787
3.5%
Non-Operating Revenue
Year 2 CAHs (n = 8)
$108,249
$104,924*
-3.1%
Comparison Hospitals (n = 10)
$121,608
$159,532
31.2%
Source: 1999, 2000 Health Care Cost Information System (HCCIS).
*One CAH reported that there were adjustments to revenue that did not appear in their HCCIS
reports. Revised figures would change CAH operating revenue to $150,161 and non-operating
revenue to $107,173 for 2000.
In the year of conversion, Year 2 CAH net patient revenue increased 13.8% over the
year prior to conversion. This compared to a difference of 11.5% for the comparison
hospitals over the same period. Further analysis over time will provide greater
information on the financial position of the CAHs in subsequent years.
The picture of other revenues is not clear. Overall, the Year 2 CAHs showed a slight
decline in other operating and non-operating revenues while the comparison hospitals
showed increases during the same time period. When the noted adjustment for one
CAH is made to the HCCIS figures, operating revenues show a slight increase and nonoperating revenues show less of a decline in the Year 2 CAHs in the year of conversion.
Overall, the Year 2 CAHs had lower patient days and average daily census counts in
the year prior conversion when compared to the sample of ten rural comparison
hospitals, even though they were operating hospitals with larger bed capacity tha n the
comparison hospitals. This was also reflected in their lower operating expense and
revenue figures. In the year of conversion, Year 2 CAH expenses rose 8.7% compared
with 9.5% for the comparison hospitals and patients revenues rose 13.8% for the CAHs
and 11.5% for the comparison hospitals. Over time, as further analysis is completed, it
will be possible to get a more detailed picture of the financial condition of CAHs in the
years following designation.
It should be noted that the financial analysis in Year 2 does not show the effect of the
two large provisions in the 2000 Medicaid Medicare SCHIP Benefits Improvement Act
(BIPA). Under BIPA, CAH reimbursement for outpatient lab services is based on
“reasonable costs.” The Medicare fee schedule typically reimburses at 35-45% of
charges with costs ranging from 60-80% of charges. The law also exempts CAH swing
56
beds from the skilled nursing facility prospective payment system. These changes
along with fully inclusive billing with the hospital receiving cost reimbursement for
hospital services and physician services reimbursed at 115% of fee schedule will
improve the financial picture for CAHs designated before BIPA.
Summary of Year 2 Findings
• Before conversion, the Year 2 CAHs were larger tha n the comparison hospitals but
showed lower average daily census and total patients days than a group of
comparison hospitals. Even though they were larger, they had lower revenues and
expenses than those of the comparison group.
• In the year of conversion, the average daily census increased in the Year 2 CAHs,
while it remained relatively flat at comparison hospitals.
• During the year of conversion, Year 2 CAHs increased their net patient revenues by
2% over the comparable hospitals.
• Based on the information available, conversion to CAH appears to have increased
revenues for the Year 2 CAHs.
57
APPENDIX A
Evaluation Design Overview
Evaluation Design Overview
Evaluation Component
1. Analysis of Grant Program
Classify the use of grant funds
Assess the outcome of activities
funded by grants
Identify problems encountered by
grantees in meeting their stated
objectives
Assess the distribution of grant
funds to hospitals
Assess ORHPC’s CAH marketing
activities
Data
ORHPC grant award
documents; grant applications
Method
Tabular presentation and
description of the uses of
grant funds
Monitoring reports; interviews
Descriptive analysis of the
with CAH grantee administrators success of conversion
assessment and implementation
planning activities undertaken by
grantees
Monitoring reports; interviews
Descriptive analysis of the
with CAH grantee administrators problems encountered by
grantees in the course of making
conversion assessments and
planning for the implementation
of CAHs
ORHPC grant award documents Geographic analysis of the
distribution of grant awards
compared to CAH eligible
facilities
ORHPC internal documents,
Tabular presentation and
newsletter, presentations, and
description of ORHPC’s CAH
collaborative activities with
marketing activities
Minnesota Hospital and
Healthcare Partnership
Comments
Objective is to assure that grant funds
are spent on activities specified in the
ORHP “Guidance for Program Grant
Funds for FY 1999”
Objective is to provide an
understanding of the usefulness of
grant- funded activities in planning for
and making the conversion to CAH
status
Objective is to provide an
understanding of possible barriers to
program implementation in Minnesota
Objective is to assure that grant funds
are reaching target hospitals
Objective is to assure that all CAHeligible hospitals are aware of the
MRHFP and that grant funds are
reaching target hospitals
Evaluation Design Overview
Evaluation Component
2. Analysis of financial
performance and utilization of
CAHs and comparison hospitals
Assess financial performance of
CAHs and comparison hospitals
Assess the utilization of CAHs
Assess the rate of transfers from
CAHs
3. Analysis of physician integration
and satisfaction with CAH
Document physician integration
activities in case study CAHs
Assess physician satisfaction with
CAHs
Data
Method
Comments
Financial records for CAHs and
comparison hospitals (e.g.
Medicare cost reports, audited
financial statements)
Tabular presentation of data with
accompanying narrative
The objective is to determine whether
conversion to CAH status improves
the financial condition of facilities
Utilization records (inpatient and
outpatient) of CAHs and
comparison hospitals
Transfer records from case study
CAHs; patient origin studies
Tabular presentation of data with
accompanying narrative
The objective is to determine how
conversion to CAH status affects use
of services
The objective is to determine how
conversion to CAH status affects the
rate and final destination of patient
transfers
Interviews with CAH
administrators; monitoring
reports
Narrative description of
physician integration practices of
case study CAHs
Interviews with CAH physicians,
local EMS medical directors,
and receiving- hospital medical
directors; satisfaction
questionnaire
Tabular presentation of
satisfaction data by providers
type (e.g., physician, nurse
practitioner, local EMS medical
director, receiving- hospital
medical directors) and narrative
assessment of physician
satisfaction
Simple quantitative analysis of
trends in transfer data, pre/post
conversion
The objective is to document the
degree of physician integration and
methods used by CAHs to integrate
physicians into their operations
The objective is to document the
degree of satisfaction with CAHs of
various medical professionals who
come into contact with CAHs
Evaluation Design Overview
Evaluation Component
4. Assessment of quality of care
delivered in CAHs
Document compliance with federal
and state licensure and certification
criteria and innovative
QA/credentialing arrangements
Data
Method
Comments
MDH Facility and Provider
Compliance CAH survey
documents; CAH credentialing
and quality assurance
agreements; interviews with
CAH administrators; monitoring
reports
Count of hospitals that have
passed certification surveys;
descriptive comparison of
components of CAH
QA/credentialing plans and
agreements
Objective is to determine whether
CAHs meet federal and state licensing
requirements and to identify and
document innovative models of
interorganizational cooperation in
regard to QA/credentialing
Assess case-study CAHs’
experience with state licensing and
certification surveys
MDH Facility and Provider
Compliance Division CAH
survey documents
Objective is to identify trends in the
experience of CAHs in regard to state
licensing and certification surveys
Assess CAHs’ on-going compliance
with their own written QA plans
CAH QA plan and QA
committee records; monitoring
reports
Assess CAH participation in special
quality studies of Stratis Health and
the state Medicaid agency
Records of Stratis Health and
state Medicaid agency
Tabular comparison of
documented survey deficiencies
at case-study CAHs prior to and
after conversion
Determine proportion of case
study CAHs that can provide
two examples over the past year
of quality problems identified
and addressed through their
systems; narrative description of
types of problems and
interventions
Narrative summary of CAH
participation in special QA
studies
Objective is to determine compliance
with facilities’ own QA programs
Objective is to document CAH
participation in external quality
assurance studies
Evaluation Design Overview
Evaluation Component
5. Assessment of resident access to
services and satisfaction with CAHs
Assess community residents’
satisfaction with CAH model
Data
Method
Comments
Community focus groups in
case-study communities
Qualitative analysis of focus
group responses; synoptic
narrative summary of responses
across groups
Objective is to determine whether area
residents are satisfied with the CAH
and its network relationships
Assess former patient’s perception
of care provided in CAHs
Community focus groups in
case-study communities (second
visit)
Objective is to determine area
residents satisfaction with the quality
of care delivered in CAHs
Assess the impact of community
satisfaction on CAH utilization
Community focus groups in
case-study communities (second
visit); utilization reports
Qualitative analysis of focus
group responses; synoptic
narrative summary of responses
across groups
Comparison of changes in
utilization with area residents’
satisfaction and perceptions of
quality
Diagram networking
relationships of CAHs and
document changes over time
Diagram networking
relationships of comparison
hospitals and compare them to
CAHs; document similarities
and differences
Objective is to determine the impact
of CAH conversion on network
development
Objective is to determine whether the
networking behavior of CAHs differs
from that of other rural hospitals
Objective is to determine the impact
of community satisfaction with the
CAH and perception of the quality of
care on utilization
6. Assessment of network
development
Document changes in networking
behavior after conversion
Document difference in networking
behavior between CAHs and
comparison hospitals
Interviews with CAH
administrators and monitoring
reports
Interviews with CAH and
comparison hospital
administrators; monitoring
reports
Evaluation Design Overview
Evaluation Component
7. Analysis of emergency medical
services (EMS) integration with
CAHs
Document components of CAH
emergency service plans (e.g. hours
of operations, referral and transfer
agreements)
Assess the impact of conversion to
CAH on the availability of
emergency room services
Assess the level of EMS integration
with CAHs
Assess the impact that MRHFP
grants have had on the local
emergency medical system
Data
Method
Comments
CAH emergency service plans
and referral and transfer
agreements and protocols;
interviews with CAH
administrators; monitoring
reports
Description of the methods
employed by CAHs to assure
emergency medical services
noting changes over time
methods
Objective is to assess the effect of
conversion to CAH on the
coordination and provision of
emergency medical services in the
community
Utilization reports; monitoring
reports (number of days and
portions of days the ER is
closed); interviews with CAH
administrators
Interviews with CAH
administrators, monitoring
reports; EMSRB, regional EMS
coordinating councils, and local
EMS agency records
Grant proposals and award
documents; monitoring reports;
interviews with CAH
administrators
Tabular presentation of data with
accompanying narrative
Objective is to document whether
conversion to CAH reduces access to
local emergency medical services
Identification and documentation
of activities bringing EMS and
CAH resources and functions
into closer coordination and/or
unified control
Description and assessment of
the impact of grant- funded EMS
integration or EMS improvement
projects
Objective is to document the degree of
EMS integration with CAHs
The objective is to provide an
understanding of the usefulness of
grant- funded activities to promote
EMS-CAH integration or improve
local emergency medical services
APPENDIX B
Community Focus Group Summaries
Community C
Community C has a population of about 2300 people and its demographics have been changing over
the past few years. The community had a sizable Somali population that has moved to a larger
nearby city. At present, there are a large number of new Hmong residents, many of whom are nonEnglish speakers. Current residents describe the new residents as “good people that are ambitious
and hard working”. With local schools consolidating with their school district, the community wants to
remain the nucleus of education activities,. They feel that the education facilities and the hospital
attract and retain businesses and residents in the community. Most of the employment is in farming
and farm related businesses. It is recognized that, due to their more inexpensive housing stock and
fairly short commuting distance, their community may become a “bedroom community” for the larger
city that is about 20 miles away. The community still talks about the major (F5) tornado they
experienced several decades ago.
Seven residents attended the focus group, including the City Administrator who also serves on the
hospital board, a high school guidance counselor and hospital board member, the owner of the
hardware store, a pastor, a loan officer at the local bank, a tax accountant and President of the local
Chamber of Commerce Board, and a resident of a nearby community served by the hospital.
In spite of general news articles about the conversion to CAH designation, resident who attended the
focus group felt that the community had a “limited” knowledge of the change. It was felt that the
community had not participated in the decision to convert.
When asked the difference between a hospital and a CAH, residents believed the difference involved
financial reimbursement. One resident said that the name Critical Access Hospital was misleading
because people thought it meant only “critical care”.
All of the residents attending the focus group said that they would use the hospital tomorrow if they
needed health care. They described the care at the hospital as “caring” and “competent” and felt that
there were enough specialists available through the CAH’s network that they could receive the range
of care needed. There was a concern that OB services were not available. Some residents felt that
when people received these services elsewhere, they tended to seek other health care there as well.
This meant they weren’t using the services available in the community. They also bemoaned the
recent loss of the provider who dealt with social/emotional and mental health needs.
Most participants at the focus group were aware of the CAH’s networking with other facilities. They
understood that there was sharing of staff and other resources with the hospital in the next
community. They felt that this was “economical” and viewed these as positive relationships for the
community.
All of the focus group participants used physicians in the community and many had used the services
of a mid-level practitioner as well. They described their experiences with these providers as
“excellent” and felt that the mid-levels had more time to spend with patients.
Community C Cont’d
In describing the quality of services at the CAH, residents said they were “very confident in the
services” of the hospital. They felt that proper tests and care were available, and that appropriate
decisions were made to transfer a patient if additional services were needed. There was concern
about billing problems and lack of clarity with billing. (This CAH undertook the quality initiative around
clarity in patient billing that is described in Chapter 4.)
When asked about the most important services tha t a hospital should offer, focus group participants
included ER services, outpatient care, specialists on a regular basis, and follow-up care for cardiac
and surgical patients. Their wish list for services not currently provided included obstetrics,
pediatrics, and mental health care.
The participants expressed no concerns about the hospital’s conversion to CAH. They were more
concerned, particularly the Board members, that in the future the CAH rules will change “in
midstream” and they will have spent money that will not be reimbursed. With regard to the future,
they would like to make sure that the community can “attract and keep doctors”, and they very much
“want the hospital here”.
Community D
Community D has a population of 750. It is described by residents as a “stable community”; one that
raised funds for the renovations at the hospital. The local sentiment was that maintaining the hospital
would keep retirees in the community when they could move elsewhere. Many senior services are
offered in the community, such as meals on wheels, transportation services, and senior housing
attached to the hospital. Community residents saw the attachment to the hospital as very important.
Five community residents attended this focus group, including a resident from town, one who lived
outside of town, a farmer, a retired farmer, and a resident who also served on the hospital board.
According to participants in the focus group, the change to CAH designation was made known to the
community via news articles, presentations at local civic groups, and was mentioned as part of the
fund raising drive to make improvements to the hospital. The community wanted to know what costs
were involved in the change and what services would be affected. Some participants at the focus
group knew that the CAH designation dealt with the “method of funding” and that this would help them
keep their hospital. One resident expressed the importance of having an ER in rural areas.
All of the focus group participants said that the y would use the hospital tomorrow if they needed care.
Members felt that there was “good care in smaller hospitals” and they felt comfortable leaving the
decision up to the medical staff as to whether they should be treated locally or transferred to another
facility.
The participants were quite aware of the hospital’s network affiliations. They commented favorably
on the diabetes care education program offered through the network and knew about physical
therapy, orthopedic specialists, and psychologists who were available through this affiliation. The
group used doctors and mid-level practitioners in the community and said they would “use the doctors
here first” before going elsewhere. They were pleased with the care provided by mid-levels. One
participant commented that she preferred seeing the mid-levels for things such as a physical exam
because they were women,. All of the focus group participants agreed that the hospital provides high
quality care.
The group felt that the most important services for a hospital to offer are ER, surgery, follow-up and
rehabilitative care, and chemotherapy. In terms of services that they would like but are not available,
they suggested cardiac rehab (which is available at another hospital in the network), a broader range
of surgeries (although they knew that major surgery costs would make that prohibitive), and a few
more diagnostic tools. They mentioned that the MRI truck comes regularly and that they do have a
good array of lab tests available.
Overall, the focus group participants expressed great support for the hospital and did not have any
specific concerns. They stressed the importance of the hospital in the community and said “people
would retire in other directions if there wasn’t a hospital”.
Community E
Community E has a population of slightly more than 1500 and was site visited shortly after a major
flood in the area. Spring flooding is quite common in this area and the residents were well aware of
its implications on their health care choices. Several mentioned the residents are in danger in such
situations. One resident pointed out that the 3 closest hospitals in other communities could not have
been reached by ground during the flood. If they did not have their hosptial in their community, the y
would not have been able to receive care during this time. The high elderly population was also a
health concern of the community. As one woman stated, “there are so many elderly in this area;
without the hospital, many would simply not get care. They don’t have the means or they have too
many barriers to getting the needed care in other communities”.
The focus group participants felt that the community was aware of the conversion to CAH or “should
have been aware—some don’t read the paper”. There were 4 or 5 articles in the local newspaper,
community presentations, and the CAH conversion information was discussed at a community
meeting where a financial consultant to the hospital presented. In terms of community participation in
the conversion decision, the group felt that “people had the opportunity to participate”. One member
said that they had the “privilege to speak one’s mind”.
When questioned about the differences between a hospital and a CAH, one resident mentioned that
there were “shorter stays at a CAH”. Others knew that there was different reimbursement from
Medicare. One said that you had to be “the only hospital in the county to be a CAH”. Several
indicated that they felt that there would be more services due to better reimbursement.
All of the focus group participants would use the hospital tomorrow if needed. One woman said, “I
would come here first and find out what’s wrong”. Many said they would only go to another facility if
their physician recommended it. Another person pointed out that “35 miles is longer if it’s rural” in
terms of getting to other places, especially during snowstorms, etc. The flood was mentioned several
times.
The participants were well aware of the network relationships of the CAH. They knew about “life
flight”, home care, and physical therapy services. They also said that “transfer are smooth” when
they need to go elsewhere. The general consensus was that the community trusts their doctors to
refer when and where necessary. All the focus group participants used physicians in the community
and were willing to use non-physician providers.
All residents attending the focus group felt that the hospital provides high quality care. They felt that
the most important services for a hospital are ER, physical therapy, cardiac rehab, regular nursing
care, and diabetes counseling. They wished there was more preventative education available and
mentioned tobacco counseling as a need.
The group’s primary concern about the future of the hospital was the fear that someday it would
close. “What would we do? The community is so thankful and appreciative to have a hospital” is how
one resident summed up the sentiments of the group. They were thankful that “the hospital has
always been there for us”.
Community F
Community F has a population of about 2000 and is described by residents as a friendly and caring
place. The focus group consisted of a minister, a part time minister and radio talk show host, an
employee of the electric co-op, the owner of a manufacturing business (who had relocated here from
the East coast), and members of the hospital auxiliary. One participant shared that he made more
friends his first year in the community than he did in “twenty years in New York”. The best part of the
community was described as the people. One participant was “overwhelmed by the genuine love and
care expressed here”. The community receives a lot of tourist traffic, especially outdoor enthusiasts
“who are friendly and outgoing”. They also noted that the community have a wonderful school system
with “fantastic staff”.
The residents attending the focus group were quite unaware of the transition to CAH. One member
said she thought, “they always were one; always took critical care patients and sometimes flew them
out” to other hospitals. There had been a presentation about the change sponsored by the Rotary
club and a story in the newspaper, but the group felt that the change was “mostly a hospital decision”,
not a community decision.
When asked the difference between a hospital and a CAH, one man said that the “CAH is staffed
24x7 whereas before that it was just doctors on call”. Now there “is always a doctor available”. The
administrator of the hospital was present at this time and spent a few minutes describing what CAH
meant for the hospital in terms of number of beds, emergency care, and reimbursement. He also
explained that it was his hope that CAH designation could help them financially so that they are able
to build a new hospital to replace their old physical plant, in order to better meet community health
needs in the future.
When asked if they would use the hospital tomorrow if needed, the participants said that they would
now, which is different from what their answer would have been in the past. Before CAH designation,
there was a “rent-a-doc” perception and the clinic “was not so welcoming”. In explaining the change,
people noted that there were some people who were “down on the community” due to changes that
had taken place. Some industry had left and people felt the sense of “community pride had left, too”.
Coupled with the lack of resident physicians, people felt that the health care they received “was not
the best”. That seems to be changing now. The hospital is “staffed with really good people, but
they’re strapped for facilities”. This is why there are plans for a new hospital building. People now
believe that “the ER staff is excellent” and the current CEO’s “involvement in the community” is
making a difference. One man who had not been admitted to the hospital said that he visited many
elderly patients there and “the hospital was very accommodating, did a fine job, and even the food
was good”. Much of the improvement had taken place in the last 6 months and people now feel that
there are many specialty appointments available and they
Community F Cont’d
go elsewhere when their doctor refers them to other care. Again the issue of a “lady doctor” was
mentioned as a reason for going elsewhere for care. One participant said that now “he would use the
hospital without hesitation”.
In terms of community awareness of network affiliations, residents learned some of this from an
article in the local paper. The article reported on home health, hospice, and shared surgeons. There
was also awareness of shared purchasing with another facility.
Most of the focus group participants would see a physician in their community. When asked about
mid-levels, one person said that there is a perception by some that “if you’re paying for a doctor you
should get to see a doctor”. Most in the group, however, had used mid-levels and felt that they are
“excellent” and “very conscientious and thorough”.
The residents attending the focus group felt that the hospital offered high quality care. They thought
that the important services for a hospital are ER, surgical and diagnostic, chemotherapy, and rehab.
Their wish list included kidney dialysis and radiation, but they were aware that some of these were
probably beyond the realistic scope of their hospital. They were thrilled, however, that their hospital
does sleep studies.
In terms of future concerns, they were all looking forward to a new hospital building in 2003. They
have a $2 million fund raising goal and are very close to reaching it. They feel the community has
been successful in recruiting two new physicians and these steps have given them a positive outlook
on the future of health care in their community.
Community G
Community G has a population of a little more than 2500 and has one of the most stable long-term
physician practices of the sites that were visited. The focus group participants included a pastor,
county commissioner, staff from the county administrator’s office, a senior services administrator and
a farmer who lived quite far outside of town. Most participants felt that the community was not
knowledgeable about the hospital or the conversion to CAH. One member said that the community
didn’t know that “the hospital was losing money”. Those attending the focus group felt that to most of
the community, critical access meant “emergency care”. The community had been informed about
CAH through the newspaper and a hospital newsletter. Members of the media were also present at
hospital board meetings. When the decision was made to convert to CAH designation, it was made
by the hospital board, which is made up of 5 county commissioners, medical staff, and one at large
member. Medical staff had input into the decision. The residents attending the focus group couldn’t
articulate the difference between a hospital and a CAH.
All of the residents at the focus group said they would use the hospital tomorrow if needed. They
have “good, trusting relationships with their doctors” and their “past experience has been good”.
Some had concerns about insurance access, however group members knew that recent negotiations
by the co-operative yielded a contract with an insurance carrier that reduces this as an issue. There
was a strong sentiment that people should “do business in town” which i ncluded health care. Focus
group participants had confidence in the quality of care. One person described how a “life was saved
because she was brought to the hospital and stabilized here before being transported for more
extensive care”.
In terms of network affiliations, the group knew that some ties existed, but were not sure with whom
or how they worked. One commented that he “saw the imaging van, but didn’t know the specifics”.
One person felt that “the visiting physicians as part of networking is what the general public sees”.
All of the focus group participants received medical care from physicians in the local physician group.
This physician group has been in practice for more than 20 years, and they recruit new physicians as
needed. They ha ve a strong missionary history and feel confident in their ability to recruit medical
staff in the future. The group members have used the services of a nurse practitioner and one
woman in the group “prefers her because she’s female”.
There was agreement that the hospital provides high quality care. The most important services for a
hospital to offer are ER, intensive care, “swing bed—to get back into the community; to get therapy to
be able to go home”, x-ray, lab, and pharmacy, and services to keep families coming, such as
midwife. The wish list of services included radiation (“almost a daily need”), faster lab services, and
better use of telemedicine.
They have no concerns about the hospital’s conversion. One group member said that they were
“fortunate to have had a culture that looked at what was coming down the line” and planning for the
future.
Community H
Community H has a population of about 2800. It is the only hospital among the Year 2 CAHs to have
focus group participants who thought that the hospital might close and that the community could
adjust to that change. The hospital administrator was employed on an interim basis. The focus
group was composed of a retired physician from the community, a school board member, a
“preacher,” a b usiness owner, a member of the hospital advisory board, the city administrator, and
the local ambulance director.
The residents felt that the community was “minimally aware” of the change to CAH. They said “it’s a
hard concept to understand” and that although there were news articles about it, they “didn’t really
clarify what it means to be a CAH”. They knew that it had something to do with “pay schedules”, but
had no more specific information. Group members said that they “didn’t know who made the decision
to convert or why”. Some knew that “fee payments” were the reason for conversion. When asked the
difference between a hospital and a CAH, several group members were able to offer information
about length of stay, Medicare reimbursement, and that CAH would “help the financial well-being of
the hospital”.
When asked if they would use the hospital tomorrow if needed, most said “generally, yes”. They said
they were most likely to use it for outpatient services. Many expressed concern about insurance,
saying their “insurance is prohibitive” in terms of where they can go for services. One said “our
insurance won’t cover us here”. Many patients don’t want to be brought to the hospital to be stabilized
because they believe their insurance won’t cover it. Many people in the community hold this
insurance coverage because they work for one of the two very large employers in the area.
The residents were familiar with network affiliations of the hospital. They knew that this brought in
certain types of specialists and allows for consultations, limited outpatient procedures, and diagnostic
testing. The hospital administrator explained that networking arrangements were in place prior to
CAH conversion, except for some additional credentialing activities. So if patients equated this with
CAH conversion, it was coincidental.
In terms of using physicians in the community, the insurance barriers were again an issue. One
person felt that the insurance coverage really drives their choices. It is more convenient to use
providers in the community and the “elderly like coming here”. This community has “a history of selfreferrals; personal relationships, perceived abilities (hearsay) drive decision-making”. Because the
community is in relatively close proximity to a major medical center, some residents choose to bypass the local facility in favor of the larger facility and greater choice of practitioners.
In terms of the quality of care perceived by the community, most focus group members felt the
hospital provides high quality care. They singled out hospice and home care as well respected
services. Community residents felt that the most important services for a hospital are ER, lab and xray, home care, physical therapy, and hospice. The wish list of services included OB services,
mammograms (this is currently a staffing issue), and urgent care.
Community H Cont’d
Finally, with respect to issues about conversion, the group noted that there was no noticeable
difference to the community. They are concerned about the future of the hospital, however, one
participant commented that “the day of the small hospital is coming to a close” and others expressed
concerns about how a small hospital can remain viable and competitive. This is the only focus group
whose participants seemed resigned to losing their hospital and remarks such as “if the writing’s on
the wall, let’s planfully get it over with” were not uncommon. They recognized that the hospital is a
“vehicle for economic development”, and also know that “everyone wants the convenience of a
primary care clinic, but when it comes to secondary care, people tend to pick and choose”. The
insurance limitations were again prominent in this discussion.
Community I
Community I has a population of about 1550 and has had a difficult history in maintaining health care
in the community. The goals articulated by the hospital administrator are to stabilize the health care
situation in the community and to plan for the future.
The residents attending the community focus group included a local realtor, members of service
clubs, and members of the hospital auxiliary, the county EMS director, a school nurse, and local
administrative officials.
Focus group participants felt that the community was “somewhat aware” of the conversion to CAH
designation. Information was provided to all of the local newspapers, and as one member explained
“it all gets out eventually”. There was a sense in the group that the CAH conversion was lost in the
many other things that were happening at the time. This community did not have stable medical care
in the past, and the hospital administrator has spent considerable effort in recruiting medical services
to the community. A new clinic has opened and there is now a stable pool of medical practitioners
available to community residents “giving care everyday”. The focus group reported that “there was
more talk about new doctors, urgent care and how it works, and new services” which overshadowed
the change to CAH designation.
In terms of the decision-making around the hospital, there were a series of events that have made a
dramatic change in the health care environment in this community. The county board made the
decision to bring in a new hospital administrator and the community members were fully supportive of
keeping the hospital open. The local school district covers 700 square miles and the hospital serves
the entire area. Previously, over the last 15 years, there had been too few medical practitioners and
they were overworked. By 1997, the doctors had pulled out, leaving no continuity of medical
services. Since then there had been “constant turnover”. One community member said:
It was easier to go elsewhere where you could establish a relationship with a doctor. The hospital
also did not accept all insurance plans and no longer had a birthing facility, which made people
look elsewhere for health care services.
According to the administrator, “the hospital is starting over with a low market share (10-12%) and it
needs to win back inpatients”. The group felt that CAH designation “is important so the hospital can
do more than just survive”.
When asked if they would use the hospital tomorrow if needed, all but one of the group members said
yes. One said “I like what I see here”. The person who was unsure said that “has never been where
I go, but I would be more inclined to use it in the future now that things are changing”. Most members
said they would have no hesitation in using the hospital in cases of broken bones, heart attack, lab
and diagnostics tests, and so on.
In terms of network affiliations, focus group participants were aware that there are quarterly hospital
district meetings and that several affiliations are represented. One group member knew that the
network hospital with whom they were affiliated had been named one of the top 100 hospitals in the
U. S. in a recent publication. One group member said he believes “the partnerships have a very
positive affect on the hospital and community because people know they have access to additional
care through these networks”.
Community I Cont’d
When asked about using doctors in the community, one participant said “there haven’t been any here
for a long time”. Now that there are doctors in the community (they practice at the clinic and conduct
daily hospital rounds), people are starting to use them. In terms of mid-level practitioners, there is
one at the hospital and only one person in the focus group had seen that professional.
When asked if the hospital provided high q uality care, one person summed it up as “we don’t have
enough personal experience to know”. One member talked about a woman who had “bad-mouthed”
the hospital, but had her life saved there twice. Another participant said that he thought a high
proportion of residents of the nursing home used the hospital. Several members said that they had
used the emergency services department and that those experiences were all excellent.
The group felt that ER, lab, x-ray, and consistent doctors were the services tha t a hospital should
provide. This is clearly a reflection of the “revolving door” of doctors that the community had
experienced over the past fifteen years. Their wish list of services included OB, kidney dialysis,
chemotherapy, and basic general surgery. The administrator noted some services that are available,
such as cardiac rehab and colonoscopy, but noted that the community was not aware of all that is
available. This is part of the mission of the new administrator.
In terms of the future, the residents attending the focus group were concerned about the age of their
hospital building and how the hospital could potentially be an economic development tool for the
community. Many participants praised the new administrator, calling him a “god-send” for the hospital
and community. They felt that conversion to CAH has helped because “people are bonding together”
and thinking about the hospital and its future. They feel they were hurt in the past by turnover in
physicians and in hospital CEOs but that this situation is improving and they are looking forward in a
positive way. The community recently undertook a community wide assessment of their educational
facilities and together as a community they built a new high school. Group members felt that this
same process would be undertaken shortly with respect to the hospital. They are hoping for a new
hospital facility within the next five years.
Community J
Community J has a population of 3600 and is characterized by an aging population. There is a lack
of employment in the community. In addition, a large number of the school age children are not
enrolled in the public school. Their families choose, instead, to send them to schools in the
neighboring city. The community has a lot of seasonal travelers passing through on their way to
tourist destinations, which puts a strain on the local EMS system. Considerable disaster planning has
occurred recently due to large forested areas nearby which were struck by high winds and are now a
major forest fire threat.
The focus group included a county board member, the director of county social services, a local bank
president, an employee of the power co-op, a doctor, a representative from the school district, and
the chief of police.
The hospital’s activities related to CAH conversion were “well-covered” in the newspaper and through
contacts with “key business and community people”. The focus group participants felt that most
people in the community “didn’t know there had been a change” and that the “public probably doesn’t
understand what it means” for the hospital. The decision to convert was seen as a hospital decision.
Most in the group couldn’t articulate the difference between a hospital and a CAH, although one
member understood that it meant that the hospital would be reimbursed “more on a cost basis”. One
participant talked about the importance of “critical care” because of the community’s location and how
the hospital was a “temporary stop” for injured people.
All of the focus group participants said that they would use the hospital if needed. Several said that
they would consult with the doctors here before going on to another facility. The chief of police stated
that if he was dealing with a major gunshot wound he would probably call a “life flight” to air transport
the victim to a major trauma center.
The group was aware of network affiliations of the hospital. These were seen as relationships that
have existed for several years, not as a result of CAH conversion. One member said that these
relationships were advantageous in purchasing, shared billing services, and reduction in duplication
of administrative services. It also increased the number of available specialists in the outpatient
clinic.
When asked about using doctors in the community, focus group participants all said they use local
doctors unless they are referred on to a specialist. There were several reservations about use of
doctors on weekends because a separate group of physicians is hired for weekend coverage and
“you never know who will be there”. One member felt this led to a lack of follow-through by these
practitioners with their “regular doctors”.
The group felt that the most important services for a hospital to offer include ER, general surgery,
physical therapy, mammograms, detox, urgent care, and referral for psychiatric care. The hospital
offers OB services, but the group did not mention it. Their wish list was detox (due to recent changes
that had occurred), wellness and prevention programs, and CT scan.
Concerns about the future were related to the community “having a vision” related to the hospital. A
group in town is pursuing a foundation grant to combine certain education and hospital services,
including a wellness center that would be attached to the high school and hospital. The aging
population and lack of job opportunities jeopardizes the future of the community, therefore the role of
health care in bringing the community together is vital.