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Hello everyone,
Happy Thanksgiving! I hope you all have a great upcoming holiday.
We enjoyed seeing many of you at the November TASC 90 the Integration of Rural Health Clinics and Hospitals. If you weren't able to attend, the webinar playback and slides are available here.
We are also looking forward to seeing you at the Virtual Knowledge Group on December 17th. This webinar will include a discussion on Flex program staff engagement, wellness best practices, and employee satisfaction. We are also preparing to send out the 2021 Flex Fundamentals Guide: An Introduction to the Medicare Rural Hospital Flexibility Program. This will be mailed to your office and also available online.
As always, thank you for reading the newsletter. If you have questions or need assistance, please do not hesitate to reach out to me or TASC.
Best, Andy Naslund Program Coordinator TASC
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Federal Office of Rural Health Policy (FORHP) Updates
Dear Flex Coordinators,
As we flow into the holiday season, I find myself reflecting on what I have been grateful for throughout the year. This year has certainly tested us, but it has made me more appreciative of the people I (virtually) surround myself with; this includes you all. I am astounded by your patience, resiliency, and adaptability in the face of so much uncertainly.
Please take note of these important upcoming due dates for your Flex Program:
- The Fiscal Year (FY) 2019 End of Year Report is due on November 30th for all Flex programs, please reach out to your Project Officer, Tori, Natalia, Tahleah, or Laura, if you have any questions.
- If your program is one of the 8 EMS Supplement awards, you have the FY 2019 Emergency Medical Services (EMS) Supplement End of Year Report due on November 29th, please reach out to Tahleah Chappel if you have questions on EMS.
- Please be on the lookout for guidance from me pertaining to your Annual Federal Financial Report (FFR) due January 30, 2021 and how to submit a Prior Approval Carryover Request by March 1, 2021.
We've also valued your input and patience as we've been working through a major revision for how the Medicare Beneficiary Quality Improvement Project (MBQIP) data reports are produced. We encourage you and your MBQIP subcontractors to participate in the December 3rd MBQIP Virtual Knowledge Group which will include a focus on the new reports. More details are here, or click here to register.
I am incredibly thankful to be working with you all. Stay Healthy, Tori
CAH Regulatory Update
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This month, we welcome to Quinyatta Mumford of Arkansas. Welcome Quinyatta!
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CAH Recognition Spotlights! Innovative Approaches to Post-Acute Care
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Critical Access Hospital Recognition was established by The National Rural Health Resource Center (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, the following three hospitals received national recognition for demonstrating an innovative approach to post-acute care that supports a patient's continued recovery from illness, or management of a chronic illness or disability:
- Harrison County Community Hospital -- Bethany, Missouri (Featured in this newsletter)
- Pinckneyville Community Hospital -- Pinckneyville, Illinois (Featured in the October newsletter)
- UPMC Cole -- Coudersport, Pennsylvania (Featured in upcoming newsletter)
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Harrison County Community Hospital (HCCH), located in Bethany, Missouri, is one of three critical access hospitals (CAHs) that received national recognition for demonstrating an innovative approach to post-acute care that supports a patient's continued recovery from illness, or management of a chronic illness or disability.
HCCH identified a lack of interdisciplinary communication regarding hospital discharges and a lack of structured post-hospital discharge follow-up when reviewing satisfaction survey scores and hospital inpatient 30-day readmissions. In April 2019, HCCH established an interdisciplinary transitions of care team to improve the discharge process, enhance communication between patients, health care providers, and other caregivers, and to reduce the likelihood of readmissions within 30 days. This team is made up of a care coordinator, nursing staff, ancillary departments, home health, primary care clinics and physicians, and a local pharmacy. The team provides post-discharge, patient-specific follow-up care at various intervals based on a risk-adjusted assessment performed upon admission.
Upon admission at HCCH, the patient is highly involved in the plan of care and discharge process. Patient preferences are taken into account by the multidisciplinary team and are the driver of daily care. The Transitions of Care team has implemented evidence-based practices to facilitate a high standard of care. The Transitions of Care team aims to provide safe care throughout the patient's stay through increased communication with the patient and across the care team. The Transitions of Care initiative provides timely post-discharge care coordination services to the patient within 72 hours of hospital discharge. The objective is to identify and prevent any potential risk factors for re-hospitalization, considering each patient's preferences. Post discharge care visits are conducted to every patient including home environmental safety observations.
From left to right: Amy Pickren, Director of Inpatient Services and Quality Management; Elisa Welp, Care Coordinator; Tina Gillespie, CEO.
Positive Outcomes
- Forty percent of all patients discharged to home received a complimentary nurse home visit, and the care coordination nurse attempted 100% of follow-up phone calls.
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- The readmission rate (11%) remained below the national average for 2019. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Care Transition scores averaged 3.5, communication about patient medications scores averaged 3.6 out of 4, and overall patient satisfaction averaged 9.1 out of 10.
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- Prior to the initiative, 40% of patients discharged to home reported that they had questions or concerns with discharge to home medication lists upon their next doctor visit. As of Quarter 1 2020, that number was reduced by more than half. Eighty-eight percent of patients surveyed stated they had a good understanding of their discharge instructions.
Top Accomplishments
The overall goal for this team is to improve patient satisfaction HCAHPS scores, lower hospital 30-day readmission rates by enhancing patient education methods, and providing structured, scheduled, timely follow-up calls and/or visits with patients after discharge. The overarching goal of the program is to improve health outcomes for all patient populations that are discharged from the hospital. This is directly linked to the hospital strategy by monitoring HCAHPs scores, sending surveys to swing bed patients upon discharge to monitor for areas of improvement for this particular patient population, and providing care coordination follow-up phone calls to identify and resolve any concerns or educational gaps.
"HCCH has developed an innovative Transitions of Care team to help patients transition to home safely," said CEO Tina Gillespie. "Our goal is to reduce or eliminate the need for rehospitalizations and to keep the patient in their own home for treatment rather than in the hospital setting."
"Harrison County Memorial Hospital is a valuable asset to the health care system. Through their excellent work, patients are receiving quality care close to home. By using population health management, high quality care outcomes are being achieved while reducing avoidable health care costs. Patients receive education throughout the community through long-term care facility care coordination, local retail pharmacy program, rural clinics integration, and hospital population follow-up care," stated Sara Davenport, Chief of the Missouri Office of Rural Health and Primary Care.
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CMS: Frequently Asked Questions for the CHART Model
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The Centers for Medicare and Medicaid Services (CMS) recently released a frequently asked question document addressing stakeholder questions regarding the Community Health Access and Rural Transformation (CHART) Model. The FAQs are posted on the CHART website.
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Community Health Access and Rural Transformation (CHART) Model
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Through the new CHART Model, CMS aims to continue addressing disparities by providing a way for rural communities to transform their health care delivery systems by leveraging innovative financial arrangements as well as operational and regulatory flexibilities.
The Rural Health Value team has been hosting " Let's Talk About CHART" virtual discussions to help rural communities and stakeholders identify opportunities, questions, and potential next steps regarding the CHART Community Track application. Webinars:
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- Lead Organization
- Transformation Plan
- Hospital Payment
- Partners
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- What it takes to serve as a Lead Organization
- Key planning and readiness activities
- Partners Lead Organizations will need and want to engage
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- December 14, 2020, 12:00 CT / 1:00 p.m. ET: Let's Talk about CHART... Transformation Planning: More details coming soon.
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National Consortium of Telehealth Resource Centers (NCTRC) Telehealth Hack
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NCTRC is now hosting the Telehealth Hack, an extension of the previously held HHS Telehealth Hack. This webinar series will continue to deliver virtual peer-to-peer webinar learning sessions to support the adoption of telemedicine across the nation. Through the end of 2020 and into the spring of 2021, NCTRC has planned several core telehealth related topic areas. The first installment was a two-part webinar series recorded in October, focused on technology and Americans with Disabilities Act (ADA) compliance. In November, expert speakers will familiarize attendees with the application of legal requirements within telehealth, and the December series will provide an overview of school and college-based telehealth.
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New from CMS: Rural Crosswalk: CMS Flexibilities to Fight COVID-19
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CMS has recently released a Rural Crosswalk: CMS Flexibilities to Fight COVID-19. This document highlights COVID-19 related provisions that CMS has issued and/or carried out during the public health emergency (PHE) that impact rural health clinics (RHCs), federally qualified health Centers (FQHCs), CAHs, rural acute care prospective payment system (PPS) hospitals, and/or Medicare-certified skilled nursing facilities (SNFs).
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Upcoming Events
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MBQIP VKG hosted by Stratis Health -- Thursday, December 3, 2020 from 2:00 p.m. - 3:30 p.m. Central Time.
SHIP Webinar hosted by SHIP TA Team -- Thursday, December 10, 2020 from 1:00 p.m. - 2:00 p.m. Central Time.
Flex VKG hosted by TASC -- Thursday, December 17, 2020 from 2:00 p.m. - 3:00 p.m. Central Time.
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MBQIP Updates
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Updated Resources
Please send your MBQIP questions to tasc@ruralcenter.org. TASC will ensure your question reaches the appropriate person.
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Webinars, Recordings & Events
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Webinar Playbacks
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The most recent interviews include a celebration of National Rural Health Day and multiple new conversations with rural health leaders.
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