Rural Route
August, 2020
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MBQIP Updates
TASC Updates
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State Flex Profiles




Rural Health Value


Hello everyone,

It is hard to believe it is already the end of August! We hope you all had a great summer season and enjoy a great start to your fall season and your new program year.

Thank you to everyone who participated in the 2020 Flex Program Virtual Reverse Site Visit (RSV). We were really pleased with how the conference turned out, and it would not have been possible without so many of you speaking, participating, and contributing to the conference. Please note the slides and recordings from the conference sessions are available here

This month's edition of Rural Route has a ton of new resources and content including the brand new Visionary Board Leadership and Transition to Value Video Series. As always, we appreciate you taking the time to read this newsletter.
If you have questions or need assistance, please do not hesitate to reach out to me or TASC.

Andy Naslund
Program Coordinator

Federal Office of Rural Health Policy (FORHP) Updates   
It was wonderful to see so many of you participate in our first-ever Virtual Flex RSV! I want to extend a huge thank you to all of the presenters who shared such incredible information with us, and to the TASC team for transitioning so impeccably to a virtual platform. As I continue to learn more about each of your programs, I am truly impressed by your innovation and resiliency.

The FORHP Project Officer Flex Team is now fully staffed! On August 3rd we welcomed Tahleah Chappel to the Hospital State Division as a Flex Project Officer (PO). Tahleah will be leading the Emergency Medical Services (EMS) Supplement Program. Read Tahleah's full bio at my full update here.

As I mentioned at the RSV, we have restructured the PO assignments to align with the Department of Health and Human Services (HHS)/Health Resources and Services Administration (HRSA)/State Offices of Rural Health (SORH) regions as much as possible. Please see this updated Hospital State Division PO Map to find contact information for your Flex, SORH, and Small Rural Hospital Improvement Grant Program (SHIP) programs.

The Flex Program Year 2 will begin on September 1st. The Flex PO team will be conducting calls with every State Flex Program to go over the Non-Competing Continuation (NCC) Progress Report and Notice of Award (NoA). Read more about these calls and Flex Program Year 2 information here.

Your upcoming Performance Improvement Measurement System (PIMS) Report is due on October 30th. There will be a technical assistance webinar on September 2nd where I will go over the PIMS 2018 Results and PIMS 2019 data collection.

The first set of the new Medicare Beneficiary Quality Improvement Project (MBQIP) Quality Reports will be sent to State Flex Coordinators on September 28, 2020. Specifically, they will be the Care Transitions (EDTC) Reports for Q1 2020 and Q2 2020. The first MBQIP Open Office Hours will provide an opportunity for State Flex Coordinators to discuss the new reports and provide feedback to FORHP.

As a reminder, the new Community Health Access and Rural Transformation Model (CHART) model from the Centers for Medicare & Medicaid Services (CMS) aims to change the way the federal government pays for health care in rural areas through two separate tracks. This two initiatives will inform what works in rural in terms of delivering care and measuring quality and are of interest to us for how we can align Flex to support those efforts that work.
 CAH Regulatory Update
This month, we bid a fond farewell to a lot of people within Flex, including Lynette Dickson, Angie Lockwood, and Julie Frankl of North Dakota, and Angie Charlet of Illinois. We wish you all well!
Please keep your Flex staff contact information current by completing the State Flex Program Contact Information Form whenever there are staffing changes in your office. 
CAH Recognition Spotlights! Innovative Care Coordination Initiatives to Improve Population Health
Critical Access Hospital Recognition was established by The Center and FORHP to recognize the excellent work in Critical Access Hospitals (CAHs) and other rural safety net providers throughout the country. In this round of CAH Recognition, these four hospitals received national recognition for demonstrating innovative care coordination initiatives to improve population health:
  • Lexington Regional Health Center -- Lexington, Nebraska (Spotlighted in this newsletter)
  • Lincoln County Medical Center -- Ruidoso, New Mexico (Spotlighted in the July newsletter)
  • Mason District Hospital -- Havana, Illinois (Spotlighted in the June newsletter)
  • Ste. Genevieve County Memorial Hospital -- Genevieve, Missouri (Spotlighted in the June newsletter)
Lexington Regional Health Center (LRHC), located in Lexington, Nebraska, was one of only four critical access hospitals that received national recognition for demonstrating innovative care coordination initiatives to improve population health.

LRHC is committed to keeping pace with health care transformation, which is key to sustaining access to health services for the community. This commitment is evident through their population health program and care coordination work with patients having chronic conditions. In 2012, through the Nebraska Hospital Association, LRHC began work with the Hospital Engagement Network to identify causes for 30-day readmissions as an area of needed improvement and shared ways to implement evidenced-based practices at the facility. By 2013, the facility had made a 33.2% reduction in readmissions but recognized an ongoing need for better care coordination with patients having chronic conditions such as obesity, diabetes, chronic obstruction pulmonary disease, and heart disease. The readmissions work was a segue to moving on to develop a full transitions of care team.

The transition care team is made up of a hospital care coordinator, clinic care coordinator, utilization review nurse, community health worker, and social workers. Some of the early interventions for this group included discharge phone calls, stratified risk assessment for readmission, improved medication reconciliation, and coordination with clinics after discharge.

In addition to these focused areas of improvement, the hospital patient care coordinator began participating in daily patient rounding. Her focus was identifying educational opportunities and offering options for additional services post hospitalization to increase patient success. LRHC continued to work on home visits, home safety visits, and extend care coordination efforts to primary care, obstetrics, and the emergency department. The care coordinators, along with the social workers set goals for the course of the hospitalization, updated patients on their care plans, and provided education to the patient on how to manage their disease process at home; all of this begins at admission. Prior to discharge the physical and or occupational therapist would complete a home safety visit to assess for mobility needs in the home and to assure a successful discharge plan.

Lexington Regional Health Center (LRHC), located in Lexington, Nebraska

Positive Outcomes
  • Lexington Regional Health Center had an 82% reduction in readmissions from 4th quarter 2012 to 2nd quarter 2017. Care coordination efforts and better management of chronic conditions were the primary drivers.
  • Patient example: A 39-year-old female arrived at emergency room by squad after being found on floor unable to get up after falling. Her admitting diagnosis included rhabdomyolysis, skin abrasions, weakness, morbid obesity, and lice infestation. The patient had a five-day inpatient stay then was readmitted to hospital in thirteen days after not being able to get off toilet. The patient had a three-day observation stay followed by a thirty-seven-day swingbed stay. During the swing-bed stay, the population health model was implemented. The patient began seeing a mental health counselor, a registered dietician, following the Ideal Protein diet protocol, and completed skilled physical and occupational therapy. This patient was discharged on Ideal Protein diet protocol, continued with mental health counseling, maintained regular visits with a registered dietician, and completed physical therapy. This patient has remained out of the emergency room and hospital since implementation of the population health model. She is now able to get out of her home and participate in her children's activities with a 102-pound weight loss.
  • Before implementing the population health model from March 2017 through March 2018, the patient had two inpatient hospitalizations, one observation hospitalization, and one swing bed hospitalization. The total bill was $68,899.73. She had four clinic visits to a clinic not associated with Lexington Regional Health Center. After implementing the population health model from April 2018 to April 2019, this patient's total bill was $9,897.00 and she continued to utilize clinical social work, physical therapy, medical nutrition therapy, the Ideal Protein diet protocol, and completed follow up visits to a primary care provider. The total cost savings from 2017 to 2018 was $59,002.73.
Top Accomplishments
In 2018, the transitional care team was able to shift their home visit model into transitional care management and chronic care management, which are now billable services. Currently, the team's efforts continue to focus on the previously implemented interventions in addition to continuing to move the practices forward. They have started to look at data and drill down readmissions by payer class, primary diagnosis, discharge disposition, behavior health comorbidities, and days since discharge. Examining this data has allowed them to continue to make strides in the quality of care they provide. They continue to work on building relationships and care practices with the assisted living facilities and nursing homes in the area through quarterly luncheons to discuss patient care collaboration.

The team continues to work closely with mental health providers to ensure that they are not only treating the medical conditions but also the behavioral health aspects that play a large role in their health practices. This is extremely important aspect in ensuring patients are successful with managing their health. The two social workers that are a part of the transition care team are both master's prepared clinical social workers that can also provide counseling services.

One of the transition team's recent focuses has been on diabetes management. For patients with diabetes, a dietician and certified diabetic educator work with them one-on-one to better understand their disease process, encouraging dietary changes and exercise. Due to the diversity of the population, classes are offered in English, Spanish, and Somalian languages. Lexington Regional Health Center was awarded a grant to provide the Diabetes Empowerment Education Program (DEEP). It is designed to help people with pre-diabetes, diabetes, relatives, and caregivers gain a better understanding of diabetes self-care. The number of diabetic education referrals has increased over three-fold.

"CAHs are uniquely positioned to identify and respond to barriers and challenges to general health," said Chief Executive Officer Leslie Marsh. "Community Health Workers are one way we work to more effectively serve our diverse community. We understand the honor, privilege, and obligation that is inherent in health care and in optimizing health through innovation. The LRHC team is working hard to make a meaningful difference in the lives of those we serve. LRHC's mission and values are not just words on the wall that serve to remind us of our purpose - they are who we are and what we do."
TASC Updates

Thank you to everyone who participated in the 2020 Flex Program Virtual Reverse Site Visit (RSV) this month on August 4th-6th. The RSV was a great success due to a collaborative effort from everyone in the Flex Program. The slides and presentation playbacks are available in the 2020 Flex Program Virtual Reverse Site Visit (RSV) Presentations collection.

Also, please note that the replay of the closing keynote session on leadership from Day 3, "Seeing 2020: Experimentation, Innovation, Opportunity" by Craig Deao of the Studer Group will only be available until September 4th on the RSV Portal for those who registered for the conference. If that session is of particular interest to you, be sure to check it out soon on the portal! 

Congratulations to John Gale, Winner of the 2020 Calico Leadership Award!

John Gale, Senior Research Associate and Director of Policy Engagement at the Maine Rural Health Research Center, and a Co-Principle Investigator of the Flex Monitoring Team, was awarded the Calico Leadership Award at the 2020 Flex Program Reverse Site Visit held virtually August 4-6, 2020. "I have worked with John for more than 20 years and throughout that time I have been struck by John's ability to meld complex policy topics with his own pragmatic understanding of the realities faced by rural health care and social service providers. In addition to leading critically important rural health research studies, John continuously reaches out to rural communities and constituents to ensure that his policy and practice recommendations reflect the challenges faced by rural health organizations to deliver and report on quality health care" commented Erika Ziller, Director, Maine Rural Health Research Center.

The Calico Leadership Award is presented annually by the Technical Assistance and Services Center (TASC), a program of the National Rural Health Resource Center (The Center), to an outstanding rural health leader. The Calico Award was created in honor of long-time rural health leader, Dr. Forest Calico, for his life-long commitment to improving the quality of rural health. This year's award was presented to John for his outstanding leadership. Over his 20+ year career at the Maine Rural Health Research Center, Gale has built on his previous experience in health care organizations and focused his academic work on the operation and function of rural delivery and safety net systems of care and the role of key rural providers, including rural health clinics and critical access hospitals.

Gale's work has impacted rural health across the globe. He has served as a lead consultant for the United Nations Office on Drugs and Crime to create a toolkit on rural substance use treatment, prevention, and recovery for policymakers in developing countries. Gale is the President-elect of the National Rural Health Association (NRHA) and currently chairs their Rural Health Policy Congress. He also chairs the policy committee for the New England Rural Health Association. Gale is a member of the Technical Expert Panel for the National Quality Forum's Measure Applications Partnerships (MAP) Rural Health Workgroup and the National Academy of Medicine's Collaborative Working Group on Community Health Needs Assessments and Principles and Practice.

See the full press release here.
Please send your MBQIP questions to TASC will ensure your question reaches the appropriate person.
Webinars, Recordings & Events
SRHT Podcast Series: Managing from the Middle: Leading Through Change
With the support of the Federal Office of Rural Health Policy, Managing from the Middle: Leading Through Change, a six-part podcast series was developed by the Small Rural Hospital Transition Project for rural hospital mid-level management. Listen to all six episodes here.
Rural Health Leadership Radio was launched to support rural health leaders in sharing stories and information about best practices and lessons learned. Check out their latest podcasts now! 

The most recent interview topics include building a network of rural hospitals and the power of collaboration along with the challenges of rural hospital CEO turnover, population health and community wellness, and a celebration of the fourth anniversary of Rural Health Leadership Radio. 

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