WY Flex Annual Report · 2019. 8. 20. · 2013 Annual Report About the Flex Program The Medicare...

Wyoming Medicare Rural Hospital Flexibility ProgramWyoming Department of HealthPublic Health DivisionOffice of Rural HealthMarch, 2014

2013Annual Report

2 0 1 3 A n n u a l R e p o rt

accomplishments

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Michelle Hoffman, Flex Program

Coordinator, Office of Rural Health (ORH),

Steve Bahmer, Director, Wyoming

Critical Access Hospital Network

(WCAHN) and Andy Gienapp, Director,

Office of Emergency Medical

Services (OEMS), reflecting on FY13

Flex Program accomplishments,

challenges and changes:

“The EMS Leadership Academy was a huge success. All you have to do is read the responses to the survey for that course; they loved it!”

“The partnership between the Wyoming Office of Rural Health and the Wyoming Institute for Population Health to conduct community health needs assessments, and to train hospitals to conduct them in the future, was a major success for a number of reasons. The process truly represented a positive and productive collaboration among numerous organizations to deliver on a key requirement for Wyoming’s CAHs.”

“A major achievement that was indirectly related to the Flex Program was the change to the Special District Hospital statute that resulted from concerted lobbying effort among the WCAHN and its member CEOs, as well as Wyoming County Commissioners and others. The legislative remedy changed the requirements hospitals must meet to seek taxing authority as a Special District hospital. Although this change does not guar-antee special district status, it does level the playing field for financially strapped hospitals in counties where much of the valuation is owned by a few, often corporate, interests. The objective of the effort was to try to make it easier for hospitals to raise revenues in support of their operations. As a result of this success, one critical access hospital has already pursued special district status, and another WCAHN member is considering it.”

“CAHs inWyomingstepped up to participate in MBQIP’s phase 3 pilot project. We viewthat as an opportunity for all of our CAHs moving forward.”

“Health information technology grants to WCAHN members were a big success this year. The funding made signi-ficant dollars available to CAHs to continue their health information technology efforts.”


About the Flex Program

The Medicare Rural Hospital Flexibility Program (Flex Program) was established through the Balanced Budget Act of 1997. It is a national program that includes Wyoming and 44 other states. In essence, the Flex Program is comprised of two components — grants to assist states in implementing state-specific program activities and an operating program that provides cost-based Medicare reimbursements to hospitals that convert to Critical Access Hospital (CAH) status. The U.S. Department of Health and Human Services (DHHS), Health Resources and Services Administration, Office of Rural Health Policy, administers the grant program. The operating component of the program is administered by the Centers for Medicare and Medicaid Services (CMS), also located within DHHS.

• Sign up and actively report Phase 1 and Phase 2 measures of the Flex Medicare Beneficiary Quality Improvement Project (MBQIP)

• Encourage CAHs to publicly report data to Hospital Compare (participation is defined as submitting data on at least one inpatient measure)

• Support CAH participation in quality reporting and benchmarking initiatives other than Hospital Compare (e.g., state and multi-state CAH quality networks)

• Assist CAHs in identifying potential areas of financial and operational performance improvement

The Wyoming Flex Program is administered by the Wyoming Department of Health, Public Health Division, Office of Rural Health. From September 1, 2012 – August 31, 2013 (FY13), the Wyoming Flex Program received $449,599 from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy to implement the Flex Program in Wyoming. Over the program’s 15 years of existence, the Wyoming Flex Program received $5,760,101 or an average of $411,436 per year.

As of September 1, 2010, the federal Flex Program priorities are as follows:

• CAH quality improvement

• CAH operational improvement

• Health systems development and community engagement

• Conversion of small rural hospitals to CAH status

WyomingFlex Program

Mission:

improve accessto & the qualityof rural health

services

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• Support CAHs in planning and implementing interventions for improving operational performance

• Develop and provide the infrastructure for multi- hospital/multi-organizational collaboratives to support performance improvement

• Support the inclusion of EMS services into local and/or regional systems of care and/or regional and state trauma systems

• Support for the sustainability and viability of EMS within the community

The Wyoming Flex Program

is currently in year four of a

five-year federal grant cycle.

The program focuses on

three of the four federal

priorities and the

following objectives:1

1 No rural hospital in Wyoming is currently considering or pursuing CAH designation.


About Wyoming Rural Health

Wyoming is the ninth largest state in land mass (97,914 square miles) but has the smallest population (582,658).2 This translates into an average of 5.95 persons per square mile in Wyoming as compared to 89.5 in the U.S (based on 2013 U.S. Census popu-lation estimates). Of its 23 counties, 17 are considered “frontier,” four are considered “rural,” and two are “urban.”3 Wyoming’s geography can be characterized by the Great Plains in the east, the Rocky Mountains in the west, and Intermontane Basins (the area between mountain ranges), and it is considered an outdoor recreation destination resulting in large population swings depending on the season and location. For example, Yellowstone National Park and Grand Teton National Park, both located in the northwestern section of the state, experienced a combined 6.14 million visitors in 2012, with the heaviest influx in July, August, and September.4

Wyoming’s hospitals consist of 27 acute care hospitals, 2 Veterans Affairs hospitals, 1 behavioral health hospital, and 1 rehabilitation hospital. Of the acute care hospitals, 16 are CAHs and 11 are prospective payment system (PPS) hospitals. There is one acute care hospital for every 21,578 people and one hospital for every 3,626 square miles of land. The state continues to rank 8th nationally in its number of hospital beds per 1,000 population (2011).5 Unlike almost all other states, the distance between hospitals, both PPS and CAH, in Wyoming typically exceeds 35 miles (62% of all hospitals). In addition, many of these miles are on secondary roads or in mountainous terrain.

Wyoming’s EMS system is based on regional and community trauma areas and there is no Level I trauma center in the state. There are 67 licensed ground transport and 12 air transport ambulance services, 203 ambulances, and 2,442 ambulance personnel in Wyoming.6 Of the ambulance personnel, approximately 72 percent are classified as part-time paid or volunteer with 1,547 working as basic emergency medical technicians (EMT-Basic), 592 EMT-Intermediate, and 303 as paramedics. Twelve percent of ambulance services are certified as Basic Life Support (BLS) services and 88 percent are certified as Advanced Life Support (ALS) services. The Wyoming EMS system made 69,500 ambulance runs in 2013. The largest service area for any one ambulance service is approximately 4,200 square miles.

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2 www.census.gov, http://quickfacts.census.gov/qfd/states/56000.html, retrieved January 2013.3 Federally defined, frontier counties are currently defined as those having less than 6 persons per square mile while urban counties are defined as those having at least one city with a population greater than 50,000.4 https://irma.nps.gov/Stats/SSRSReports/Park%20Specific%20Reports/ Annual%20Park%20Recreation%20Visitation%20(1904%20-%20Last% 20Calendar%20Year)?Park=GRTE, retrieved February 2014.5 http://www.statehealthfacts.org/comparetable.jsp?ind=384&cat=8&sub= 94&yr=138&typ=1&sort=a, retrieved January 2013.6 This does not include the 1,864 Basic Emergency Care Providers.


Flex Program Partners

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Wyoming Department of Health, Office of Rural Health (ORH)

The ORH oversees four federal grant programs and four state-funded programs. Its mission is “to enhance access to healthcare service, support the development of an adequate healthcare workforce, and promote collaboration in expanding comprehensive, community-based healthcare in rural Wyoming.”

http://health.wyo.gov/rfhd/rural/index.html

Wyoming Hospital Association (WHA)

The WHA is a member-owned, private, non-profit organization representing Wyoming hospitals. As stated in its mission, “WHA is a statewide Association dedicated to providing leadership and representation and advocacy for Wyoming hospitals. The Association through leadership and collaboration, among all healthcare providers, promotes information and education that enables Wyoming hospitals to deliver high quality, adequately financed/cost-effective healthcare that is universally accessible to all Wyoming citizens.” WHA serves as the voice of Wyoming hospitals before local, state, regional and national legislative and regulatory bodies, the media and the general public. While the Association's primary focus is representation and advocacy for Wyoming hospitals, WHA also provides data services, educational programs, and a variety of other membership services.

http://www.wyohospitals.com/

Wyoming Critical Access Hospital Network (WCAHN)

The WCAHN is a consortium of 16 rural hospitals in Wyoming. It was formed for the purposes of sharing resources, continuing education, promoting operational efficiencies, and improvinghealthcare services for member hospitals and the rural communities they serve. It is an affiliate of the WHA in partnership with the Wyoming ORH. Its mission is to, “serve as a vehicle for cooperation to strengthen critical access hospitals in Wyoming.” The board of the Network is composed of CEOs from member hospitals.

http://www.wcahn.org/

Wyoming Department of Health, Office of Emergency Medical Services (OEMS)

The OEMS provides oversight to a variety of programs. It is responsible for enhancing the statewide EMS system which is designed to reduce the number of pre-hospital deaths and the severity of critical injuries and illnesses during a medical emergency when time and care make a difference. The OEMS is charged with maintaining the statewide EMS system; developing, implementing and maintaining the statewide trauma system; and assuring that Wyoming has a poison control center that will provide immediate and correct treatment information on poisoning.

http://wdh.state.wy.us/sho/ems/

Rural Health Solutions

Rural Health Solutions provides research, policy, evaluation, and program planning, development, and implementation services for organizations focused on the needs of rural populations and the organizations that serve them.

www.rhsnow.com


Flex Program Partners

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Mountain-Pacific Quality Health

Mountain-Pacific Quality Health is the state’s Quality Improvement Organization (QIO). They are an affiliation of four related corporations dedicated to improving the quality of healthcare and assuring the most appropriate utilization of healthcare services.

http://www.mpqhf.org/janda/index.php

Quality Health Indicators (QHi)

QHi is a Web-based benchmarking program specifically designed to meet the needs of small rural hospitals and to demonstrate healthcare quality in rural America. QHi is a multi-state project developed by the Kansas Rural Health Options Project (KHROP) and supported by the Kansas Office of Rural Health, the Kansas Hospital Education and Research Foundation (KHERF) and the Kansas Hospital Association (KHA).

www.qualityhealthindicators.org


WYOMING 2012-2013 FLEX PROGRAM ACTIVITIES UPDATE

The Wyoming Flex Program received $449,599 in funding for the 2012 – 2013 grant year (FY13). Grant funding was predominantly directed to CAH performance improve-ment; however, all funding was directed to activities that impact rural communities and, in particular, those that CAHs serve. Below are highlights of how the program funding was allocated, the organizations that received funding and the level of funding they received, and CAH program participation levels according to program activity.

Program Administration and StaffWyoming Flex Program funding was directed to the following organizations to complete project activities: Wyoming Hospital Association (38.5%), Wyoming Institute of Population Health (22.2%), State Office of EMS (13.7%), Office of Rural Health (11.6%),Rural Health Solutions (8.9%), subcontracts to CAHs (2.2%),7 and Kansas Health Education and Research Foundation (2.9%). Program administration and staffing costs included .82 full-time equivalents (FTE) at the ORH and 0.5 FTEs at WHA. Staff at the ORH manage all contracts, coordinate program activities, provide technical assistance to CAHs, manage subcontracts, and meet all federal grantee reporting requirements. Staff at the WHA coordinate and implement all WCAHN activities, such as the leadership training program and website and IT consultation, as well as responding to CAH technical assistance needs, managing subcontracts with CAHs and vendors, and facilitating various training opportunities.

There were two WCAHN meetings during the grant year: September 27, 2012 and March 5, 2013. Meeting agendas featured the Medicare Beneficiary Quality Improvement Project (MBQIP), Lean/Six Sigma, 340-B Drug Pricing Program,8 hospital needs assessments, and changes to state regulations. The Wyoming Institute of Population Health provided community health needs assessment support to CAHs through data sharing and training, as well as conducting community health needs assessments.

Rural Health PlanningA Flex Program strategic planning session was held April 2, 2013 in Casper, Wyoming. The strategic planning session outcomes guided the development of the Wyoming Flex Program 2013– 2014 federal grant application. The planning session was an opportunity to: 1) discuss ongoing and new challenges facing Flex Program stakeholders, in particular CAHs and local EMS; 2) update stakeholders on state and federal program changes; 3) review, discuss, and make changes to state Flex Program objectives and activities; 4) offer networking opportunities between all stakeholders; and 5) align and identify opportunities for the Flex Program, Wyoming Critical Access Hospital Network (WCAHN), Wyoming Department of Health, Office of Rural Health and Office of Emergency Medical Services, Wyoming Hospital Association, and Mountain-Pacific Quality Health to leverage their resources to better meet the quality and performance needs of CAHs and rural EMS. While it was determined that most FY13 Flex Program activities should continue, program changes were recommended. A Flex Program strategic planning session is planned for FY14.

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7 This figure only includes subcontracts between the state office of rural health and CAHs and does not include any subcontracts made to CAHs through the WHA using Flex Program funds.8 The 340B Program requires drug manufacturers to provide outpatient drugs to eligible healthcare organizations/covered entities at significantly reduced prices.

RICK SCHROEDERNorth Big Horn Hospital

CHAD TURNERStar Valley Medical Center

RYAN SMITHConverse Co. Memorial Hospital

ERIC BOLEYSouth Lincoln Medical Center

MAUREEN CADWELLWeston Co. Health Services

BILL PATTENPowell Valley Healthcare Services

JIM CUSSINSPlatte Co. Memorial Hospital

GARY POQUETTENiobrara Health & Life Center

SHARLA ALLENWyoming Dept. of Health, PublicHealth Div, Office of Rural Health

MICHELLE HOFFMANWyoming Dept. of Health, PublicHealth Div, Office of Rural Health

ANGELA VAN HOUTENWyoming Dept. of Health, Public Health Div, Health Readiness & Response Section

ANDY GIENAPPWyoming Dept. of Health, Office of EMS

KELLI PERROTTIWyoming Dept. of Health, Office of EMS

STEVE BAHMERWyoming Critical Access Hospital Network

DAN PERDUEWyoming Hospital Association

DEB FLEMINGMountain-Pacific Quality Health

SHANELLE VANDYKEMountain-Pacific Quality Health

BELINDA WILLSONMountain-Pacific Quality Health

ROCHELLE SCHULTZ SPINARSKIRural Health Solutions (facilitator)

casper, 4/2/2013

19 participants @ planning session



Subcontractual Arrangements with CAHs and EMSSubcontracts were made available directly through the Flex Program, WCAHN, and the OEMS. CAH subcontracts were for health information technology (HIT) consulting reimbursements to four CAHs totaling $66,902, $10,000 in subcontracts for various CAH-specific performance improvement activities in 11 CAHs, and $10,300 for EMS agency subcontracts for training needs.

TrainingFlex Program training targeted both CAH and EMS staff. CAH performance improvement training was provided by Laramie County Community College as part of the Healthcare LeadershipTraining Program. FY13 was the fourth year of offering this program created by the Wyoming Flex Program specifically for CAH staff. The web-based courses covered a variety of topics, including: Human Resources for Managers, Essentials of Leadership, Coaching for Success, Leading Change, as well as ten other topics. For the first nine courses, 130 participated. Eight additional courses were also held over the course of the year with 350 registrations. Six CAHs had staff participate in the first nine courses, with an average of 14 participants per course. Hospitals in Cody and Powell had the greatest representation with 67 percent of all course registrations.

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HOSPITAL NAME CITY HOSPITAL NAME CITY

Star Valley Medical Center Afton Weston County Health Services NewcastleSouth Big Horn County Hospital Basin Powell Valley Healthcare PowellJohnson County Healthcare Center Buffalo Memorial Hospital of Carbon County RawlinsWest Park Hospital Cody Crook County Medical Services SundanceMemorial Hospital of Converse County Douglas Hot Springs County Memorial Hospital ThermapolisSouth Lincoln Medical Center Kemmerer Community Hospital TorringtonNorth Big Horn Hospital Lovell Platte County Memorial Hospital WheatlandNiobrara Health and Life Center Lusk Washakie Medical Center Worland

TABLE 1: WYOMING’S 16 CAHs

CAH ConversionNo small rural hospitals converted to CAH status in FY13. One clinic will be exploring CAH designation in Wyoming in FY14.

participantcomments from the leadershipcourse

“Wonderful.Now I have some

ideas to deal with theproblems I’ve been

struggling with.”

“This course wasvery beneficial to my

professional development.I was challenged several

times and policy will changebecause of it. Your

experience and suggestionswere greatlyappreciated.”



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Wyoming EMS staff participated in Flex Program-funded EMS instructor course training, EMT-Basic and EMT-Intermediate courses,Abbreviated Injury Scale (AIS) Coding Workshop, EMS Leadership Academy, and a statewide EMS planning session. Eleven EMS agencies received EMT training support and one instructor was trained. In addition, 108 EMT-Basics were trained at eight sites, including four CAH communities: Kemmerer, Lovell, Powell, and Worland. Ten EMT-Intermediates were also trained at two other sites.

The EMS Leadership Course consisted of one Level I and one Level II course that included a total of 41 participants representing 12 CAH sites. A comprehensive evaluation was conducted for the courses with an average score of 4.7 across nine measures on a scale of 1-5 (5 being most favorable).

Technical Assistance and SupportTechnical assistance and support was provided to all CAHs and rural EMS agencies during FY13. This was made available through CAH site visits, webinars and conference calls, and one-on-one assistance as requested. Examples of technical assistance andsupport can be seen through facilitated WCAHN meetings; bi-monthly, QHi user group webinars; CAH staff requests via email for assistance and/or resources; and MBQIP support and guidance.

Meetings and ConferencesAs reported in Table 2, three CAHs were awarded funds for staff participation in regional and national conferences, including: the National Rural Health Association’s Policy Institute, Western Regional Flex Conference, Northwest Regional CAH Conference, and Studer Conference. Meetings and conferences were also facilitated through WCAHN and the QHi User Group. Flex Program funding of $4,372.15 supported the 43rd Annual Wyoming Trauma Conference which hosted 304 attendees. In addition, regional trauma meetings were held at three sites along with a state meeting.

TravelThe Wyoming Flex Program has been committed to supporting CAHs’ participation in all Flex Program activities through reimbursement for travel costs. This has been particularly important for hospitals that must travel a long distance, often times on secondary roads, to attend events. Six CAHs took advantage of travel reimbursement in FY13.



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LEVEL2

LEVEL1

Community Hospital

Crook County Memorial Hospital

Hot Springs Community Memorial Hospital

Johnson County Healthcare Center

Memorial Hospital of Carbon County

Memorial Hospital of Converse County

Niobrara Health and Life Center

North Big Horn Hospital District

Platte County Memorial Hospital

Powell Valley Healthcare

South Big Horn County Hospital District

South Lincoln Medical Center

Star Valley Medical Center

Washakie Medical Center

West Park Hospital

Weston County Health System

Others

Total

TABLE 2: FLEX PROGRAMINVOLVEMENT BY CAH

QHi

QHiUSER

GROUPMEETINGS

(TOTALATTENDANCE)HOSPITAL MBQIP

HITFUNDING

($)

NATIONALTRAINING,MEETINGS,& CONFSCITY

Torrington

Sundance

Thermopolis

Buffalo

Rawlins

Douglas

Lusk

Lovell

Wheatland

Powell

Basin

Kemmerer

Afton

Worland

Cody

Newcastle

16 CAHs

1

1

1

1

1

1

1

7

5

1

3

7

3

4

4

5

10

42

1

1

1

1

1

1

1

1

1

1

1

1

1

1

14

24,466.92

12,371.78

13,829.33

16,234.00

66,902.03

PIFUNDING

($)

909.09

909.09

909.09

909.09

909.09

909.09

909.09

909.09

909.09

909.09

909.09

9,999.99

1

2

1

FLEXPROGRAMPLANNINGSESSIONS

1

1

1

1

1

1

1

1

10

18

HEALTHCARELEADERSHIP

TRAINING PROGRAM(TOTAL COURSEATTENDANCE)

2

2

7

26

70

14

9

130

EMSTRAINING

($)

EMSLEADERSHIP

ACADEMYAIS

CODING

1

1

1

1

1

1

1

1

1

16

25

1

3

1

1

1

1

1

10

19

1

3

1

2

1

1

1

1

11

22

1,600

1,000

500

500

1,000

1,000

1,000

1,000

900

10,300

Flex Program Quality Improvement (QI) activities were administered and managed by Rural Health Solutions and the ORH. Rural Health Solutions administered QHi and the ORH administered grants and activities associated with MBQIP.9 All CAHs were encouraged to participate in MBQIP, and all but two had a signed agreement in place by the end of the grant year. In addition, all CAHs in the state participated in Hospital Compare, the Centers for Medicare and Medicaid’s Services’ public reporting program.10

QHiQHi is a Web-based benchmarking program specifically designed to meet the needs of small rural hospitals and to demonstrate healthcare quality in rural America. QHi is a multi-state project that includes 15 states. It was developed by the Kansas Rural Health Options Program (KRHOP) through funding from the Kansas Office of Rural Health and is supported by the Kansas Hospital Education and Research Foundation and Kansas Hospital Association.11 Eight indicators (four quality, two staff, and two financial) are identified in QHi as “core measures.” All rural hospitals participating in QHi are to submit data on at least the core measures on a monthly basis. In FY13, Wyoming’s Flex Program directed $13,200 to QHi for CAH participation. During this time, seven CAHs (43%) in Wyoming participated in the project and five CAHs were active users. This is a decline in participation when compared to prior years. CAHs participating in QHi also participated in six bimonthly QHi User Group meetings. These meetings were aimed at discussing changes to QHi and QHi measures, sharing best practices, learning from expert resources, and providing other Flex Program updates, including those related to MBQIP.

Table 3 identifies CAHs that entered data into QHi for any month during FY13, CAHs that actively entered data for each of the QHi core measures, and the number of months that each CAH ranked in the Top 5 of the highest performing CAHs nationally that are participating in QHi. Of the 330 users in QHi, Wyoming CAHs were most likely to rank in the Top 5 for healthcare associated infections. South Lincoln Medical Center was the most likely to rank in the top 5 during the grant year and was in the top 5 for 10 of 12 months for having the least healthcare associated infections and unassisted inpatient falls per 100 inpatient days.


QUALITY IMPROVEMENT (QI)

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QUARTERSIN TOP 5*

ACTIVEUSER*

QUARTERSIN TOP 5*

ACTIVEUSER*

QUARTERSIN TOP 5*

ACTIVEUSER*

QUARTERSIN TOP 5*

ACTIVEUSER*

Memorial Hospital of Converse CountyNorth Big Horn HospitalSouth Big Horn Hospital DistrictSouth Lincoln Medical CenterStar Valley Medical CenterWest Park HospitalWeston County Health Services

TABLE 3: QHi PARTICIPATION AND RANKINGS

QHi USE AND OUTCOMES

DataEntered

HealthcareAssociated

Infections Per 100Inpatient Days

HOSPITAL NAME

UnassistedPatient Falls

Per 100Inpatient Days

PneumococcalImmunization -

Age 65and Older

HeartFailure

DischargeInstructions

9 Rural Health Solutions began administering QHi in February 2011.10 http://www.medicare.gov/hospitalcompare/search.html?AspxAuto DetectCookieSupport=1

11 www.qualityhealthindicators.org

00010018

4

10

1

7

12

10

1

32

* Note: A CAH is considered an “active user” if they enter data for at least 10 of 12 months during the year. Top 5 is calculated on a monthly basis using a three-month average (current month and two prior months).



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12 http://www.cdc.gov/nhsn/RA/PDF/csteWorkshopDHQP6709Final.pdf

Data in Charts 1-4 reflect Wyoming CAH’s participation and outcomes as reported in QHi. Unique to small rural hospitals is low patient volume, which is not always evident when reviewing quality reporting outcomes. Six CAHs reported quality improvement data for each measure in FY13; however, for all measures, not all CAHs had patients to report on each month. Therefore, these small numbers can result in the appearance of significant monthly improvement or decline but instead, the changes may only be the result of limited patient volume.

Considering the data over the past two years (September 1, 2011 – August 31, 2013), the two-year average for healthcare associated infections per 100 inpatient days was .48, inpatient unassisted patient falls was .44, and the percent of people receiving recommended care for pneumococcal immunization (age 65 and older) was 86.4 percent and for discharge instructions for heart failure was 90.4 percent. There are no national CAH-specific comparative data outside of QHi available for healthcare associated infections; however, in 2009, the Centers for Disease Control (CDC) reported national data reflecting a rate of 9.3 per 1,000 acute inpatient days.12 Wyoming CAHs participating in QHi had a lower rate of providing recommended care for pneumococcal immunization when compared to CAHs nationally (90%); however, they performed better than CAHs nationally for heart failure discharge instructions (84.2%).

QUALITY Healthcare Associated

Infections Per 100Inpatient Days

Unassisted Patient FallsPer 100 Inpatient Days

Pneumococcal Immunization –Age 65 and Older

Discharge Instructionsfor Heart Failure

PERFORMANCE Benefits as a

Percentage of Salary

Staff Turnover

Gross Days in AccountsReceivable

Days Cash on Hand

QHi CoreIndicators

Healthcare Associated Infections per 100 Inpatient DaysCHART 1: WY (N=6) ALL QHi (N=184)

MONTH

RATE

PER

100 P

ATIE

NTS 1.6

1.41.2

10.80.60.40.2

0 2011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08 2012-09 2012-10 2012-11 2012-12 2013-01 2013-02 2013-03 2013-04 2013-05 2013-06 2013-07 2013-08

0.93 national rate for all hospitals*

* Source: http://www.cdc.gov/nhsn/RA/PDF/ csteWorkshopDHQP6709Final.pdf (2009)

1.21.11.00.90.80.70.60.50.40.30.20.1

0 2012-09 2012-10 2012-11 2012-12 2013-01 2013-02 2013-03 2013-04 2013-05 2013-06 2013-07 2013-082011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08

Unassisted Patient Falls per 100 Patient DaysCHART 2: WY (N=6) ALL QHi (N=191)

Range of 0.13 - 0.89 national rate for all hospitals*

* Source: http://www.qualitymeasures.ahrq.gov/ content.aspx?id=36944 (2012)



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Pneumococcal Immunization – Age 65 and OlderCHART 3: WY (N=6) ALL QHi (N=146)

MONTH

RATE

PER

100 P

ATIE

NTS

100908070605040302010

0 2012-09 2012-10 2012-11 2012-12 2013-01 2013-02 2013-03 2013-04 2013-05 2013-06 2013-07 2013-082011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08

PERC

ENT

OF P

ATIE

NTS

RECE

IVIN

G RE

COMM

ENDE

D CA

RE

MONTH

100908070605040302010

0 2012-09 2012-10 2012-11 2012-12 2013-01 2013-02 2013-03 2013-04 2013-05 2013-06 2013-07 2013-082011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08



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13 http://www.healthcare.gov/compare/ 14 http://www.flexmonitoring.org/wp-content/uploads/2007/04/FMT-BP-331.pdf

For FY14, CAHs have agreed to make falls prevention an area of focus. This will occur using QHi for data collection, reporting, and benchmarking, along with the Flex Program providing tools, resources, and expertise through QHi User Group meetings and on a Wyoming Quality Improvement website.

Hospital Compare and MBQIPHospital Compare, created by the U.S. Department of Health and Human Services and administered by the Centers for Medicare and Medicaid Services, is a Medicare tool that helps compare the quality of care in hospitals. It provides a list of U.S. hospitals along with their demographics (location, hospital type) and 44 quality-of-care measures.13 Hospitals participating in Hospital Compare report data for the measures on a quarterly basis. Although Prospective Payment (PPS) hospitals are required to report data for process and outcome measures to Hospital Compare, CAHs are not. In an effort to encourage CAH participation in Hospital Compare and to improve timely access to data reported, CAHs are encouraged to participate through MBQIP. CAHs participating in MBQIP agree to report rural-relevant quality improvement measures to Hospital Compare and authorize the federal Office of Rural Health Policy and state offices of rural health to access their hospital-specific data prior to its public release. During FY13, all CAHs in Wyoming participated in Hospital Compare and 14 (or 87.5%) had signed agreements for MBQIP. Wyoming is one of only 12 states with all of its CAHs reporting data to Hospital Compare.14 Table 2 on page 9 includes a listing of all CAHs that have signed agreements to participate in MBQIP.

Discharge Instructions – Heart FailureCHART 4: WY (N=6) ALL QHi (N=165)

National average of 94% for all hospitals.*

* Source: http://www.huntingtonhospital.com/ Main/HeartFailureCare.aspx (2012)

MONTH

PERC

ENT

OF P

ATIE

NTS

RECE

IVIN

G RE

COMM

ENDE

D CA

RE

CHART 6:



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15 http://www.flexmonitoring.org/documents/HospCompare/Wyoming2012.pdf, http://www.flexmonitoring.org/documents/HospCompare/Wyoming_2011.pdf, http://www.flexmonitoring.org/documents/HospCompare/results2008/Wyoming_2010.pdf, http://www.flexmonitoring.org/wp-content/uploads/2014/01/Wyoming-Report-2.pdf

Although Hospital Compare reporting began in 2005, MBQIP data were first released to state offices of rural health in FY13. The Flex Program Monitoring Team has reported CAHs’ Hospital Compare data on an annual basis since 2007, supporting additional state and national longitudinal analysis of CAH quality improvement trends. Charts 5 through 9 include U.S. hospitals’, all CAHs’, and Wyoming CAHs’ Hospital Compare data for pneumonia and heart failure measures. These data were selected for reporting, as all CAHs participating in MBQIP were required to report these measures for the duration of FY13. Looking at Charts 5 through 9, on average U.S. hospitals and CAHs nationally are making annual gains towards increasing the percent of hospital patients receiving recommended care. In Wyoming, annual improvements are mostly visible in two of the heart failure measures. For one of the measures—heart failure patients given discharge instructions—Wyoming CAHs continue to be significantly below the national average for all hospitals. During FY13, Mountain Pacific Quality Health conducted a series of webinars to support CAHs in making improvements in this process measure. FY14 data will indicate whether this support had an impact.

CHART 5: Pneumonia Measures15: Blood Culture Prior to First Antibiotic

ALL CAHs (N=908) ALL Hospitals in US (N=4,213)WY CAHs (N=13)

100908070605040302010

02008 2009 2010 2011 1st Q 2013

Perc

ent o

f Pat

ients

Rec

eivin

gRe

com

men

ded

Care

ALL CAHs (N=908) ALL Hospitals in US (N=4,213)WY CAHs (N=13)

100908070605040302010

02008 2009 2010 2011 1st Q 2013

Perc

ent o

f Pat

ients

Rec

eivin

gRe

com

men

ded

Care

Pneumonia Measures15: Most Appropriate Initial Antibiotic(s)

CHART 7:Heart Failure Measures16: Patients Given Discharge Instructions

Perc

ent o

f Pat

ients

Rec

eivin

gRe

com

men

ded

Care



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16 Ibid

100908070605040302010

02008 2009 2010 2011 1st Q 2013

ALL CAHs (N=908)

ALL Hospitals in US (N=4,213)

WY CAHs (N=13)

100908070605040302010

02008 2009 2010 2011 1st Q 2013

1009080706050403020100

2008 2009 2010 2011 1st Q 2013

Perc

ent o

f Pat

ients

Rec

eivin

gRe

com

men

ded

Care

Perc

ent o

f Pat

ients

Rec

eivin

gRe

com

men

ded

Care

CHART 8:Heart Failure Measures16: Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function

CHART 9:Heart Failure Measures16: Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)

ALL CAHs (N=908)


WY CAHs (N=13)

ALL CAHs (N=908)


WY CAHs (N=13)



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17 http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ HospitalQualityInits/downloads/HospitalHCAHPSFactSheet201007.pdf 18 http://www.flexmonitoring.org/wp-content/uploads/2007/04/FMT-BP-331.pdf 19 http://www.flexmonitoring.org/wp-content/uploads/2012/08/Hospital-Compare- Report-Year7.pdf

By the end of FY13, CAHs were also required to report Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measures and outpatient measures 1 – 7 to Hospital Compare as a part of MBQIP. HCAHPS is “a standardized survey instrument and data collection methodology that has been in use since 2006 to measure patients' perspectives of hospital care.”17 The Flex Program Monitoring Team reports that by the end of 2011, 62.5 percent of CAHs in Wyoming were reporting HCAHPS measures to Hospital Compare as compared to an average of 41.3 percent of CAHs nationally.18 They also report 43.8 percent of CAHs reporting outpatient measures as compared to 27.3 percent nationally. This high level of unmandated reporting should be expected, given the long history of CAHs in Wyoming reporting to Hospital Compare. Table 6 shows Wyoming HCAHPS and outpatient measurement reporting over time.19

For FY14, the Wyoming Flex Program will continue to aim for 100 percent participation in all MBQIP measures by CAHs in the state. Accomplishing this goal will continue to be a joint effort of the CAHs, Wyoming Flex Program, Mountain Pacific Quality Health, Rural Health Solutions, and WCAHN.

TABLE 6: HCAHPS AND OUTPATIENT MEASURE REPORTING: WYOMING CAHS AND CAHS NATIONALLY

WYOMING CAHs CAHs NATIONALLY

200720082009201020112012

YEAR# of

CAHsOutpatient

DataHCAHPS

Data

141415161616

NANA

33.3%31.3%43.8%81.25%

NA57.1%53.3%62.5%62.5%62.5%

# ofCAHs

OutpatientData

HCAHPSData

891914943977

1,0591,332*

NANA

15.9%21.2%27.3%

NA

NA34%

35.4%38%

41.3%NA

* Based on June 30, 3013 data



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20 http://www.flexmonitoring.org/wp-content/uploads/2014/01/Wyoming-Report-2.pdf, p.4

It is widely known that CAHs nationally perform well on HCAHPS measures. This is evidenced by the 2011 Hospital Compare data reported by the Flex Monitoring Team as shown in Table 7. Although Wyoming CAHs perform the same as or better than U.S. hospitals as a whole on all but two of the Flex Monitoring Team reported HCAHPS measures, they perform below CAHs nationally on all but two measures. Now that more timely data are available through QHi and MBQIP, the Flex Program can better support CAHs in further advancing patient satisfaction statewide.

TABLE 7: HCAHPS RESULTS FOR CAHs IN WYOMING, NATIONALLY, AND U.S. HOSPITALS20 PERCENT OF PATIENTS WHO REPORTED...

WYOMING(n=10)

Nurse always communicated well

Doctors always communicated well

Patient always received help as soon as wanted

Pain was always well controlled

Staff always explained about medications before giving them to patient

Yes, staff gave patient information about what to do during recovery at home

Area around patient room was always quiet at night

Patient room and bathroom were always clean

They gave an overall hospital rating of 9 or 10 (high) on a 1- 10 scale

They would definitely recommend the hospital to friends and family

CAHs NATIONALLY(n=548)

ALL US HOSPITALS(n=4,609)

AVERAGE

80%

82%

75%

70%

65%

86%

61%

75%

65%

68%

81%

85%

74%

73%

67%

85%

64%

80%

73%

73%

77%

81%

65%

70%

62%

83%

59%

72%

69%

70%

Wyoming CAH finances, like most other states, are not merely based on patient volume, reimbursement, operations, and management. This is because there are community-specific factors that also play an important role, in particular, primary payments sources (e.g., Medicare, Medicaid, or self-insured) and whether the hospital receives any community tax funding or other local subsidies.

As a group, CAHs in Wyoming have improved or maintained their financial status since converting to CAH status. A small number of CAHs continue to struggle or have significant annual positive and negative fluctuations in key financial indicators. The primary data sources used by the Wyoming Flex Program to track CAH financial trends are Flex Monitoring Team data and reports and QHi performance improvement data.

Charts 10-12 highlight key financial indicators (total margin, days cash on hand, and days revenue in accounts receivable) as reported by the Flex Monitoring Team.21 These data are used because they provide a historical perspective of CAHs’ financial performance and can be compared to current data as reported in QHi. The Flex Monitoring Team data show that the median total margin of Wyoming CAHs is consistently higher than CAHs nationally; however, there continue to be at least two Wyoming CAHs that fall below the national median or below the national benchmark (2011 comparison data used).22 The data also show that although Wyoming CAHs were above the national median for days revenue in A/R, until 2011, they were making improvements towards achieving the benchmark of less than 53 days. In 2011, data reflect less favorable outcomes with an increase in the state median and more than half of Wyoming CAHs being above the national benchmark. For days cash on hand, Wyoming CAHs tend to be at or above the national median.


CHANGES IN CAHS’ FINANCIAL STATUS

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21 www.flexmonitoring.org 22 For 2000: N=4, 2001: N=12, 2002: N=18, 2003: N=17, 2004: N=24, 2005: N=26, 2006: N=21.



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1086420 2005

COST REPORT YEAR

ANNUAL CHANGE IN TOTAL MARGIN: WY AND US

2006 2007 2008 2009 2010 2011

CHART 10:

Changes in Total Margin

# OF WY CAHs BELOWNATIONAL MEDIAN

US CAHs' MEDIANTOTAL MARGIN

WY CAHs' MEDIANTOTAL MARGIN

FLEX MONITORINGTEAM BENCHMARK (>3) * Note: For years 2005 – 2010, this number represents the number of CAHs above the national median. 2011 national data are not

available and therefore this number represents the number of Wyoming CAHs below the Flex Monitoring Team benchmark.

COST REPORT YEAR

ANNUAL CHANGE IN DAYS CASH ON HAND: WY AND USCHART 11:

Changes in Days Cash on Hand


US CAHs' MEDIANDAYS CASH-ON-HAND

WY CAHs' MEDIANDAYS CASH ON HAND

FLEX MONITORINGTEAM BENCHMARK (>60)

* Note: For years 2005 – 2010, this number represents the number of CAHs above the national median. 2011 national data are not available and therefore this number represents the number of Wyoming CAHs below the Flex Monitoring Team benchmark.

200

150

100

50

0 2005 2006 2007 2008

# OF CAHs

1086420

DAYS

2009 2010 2011



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COST REPORT YEAR

ANNUAL CHANGE IN DAYS REVENUE IN ACCOUNTS RECEIVABLE (A/R): WY AND USCHART 12:

Changes in Days Revenue in Accounts Receivable


US CAHs' MEDIAN TOTAL NET DAYS REVENUE IN A/R

WY CAHs' MEDIAN NET DAYS REVENUE IN A/R

FLEX MONITORINGTEAM BENCHMARK (<53)

* Note: For years 2005 – 2010, this number represents the number of CAHs above the national median. 2011 national data are not available and therefore this number represents the number of Wyoming CAHs below the Flex Monitoring Team benchmark.

80604020

0 2005 2006 2007 2008

# OF CAHs

1086420

DAYS

2009 2010 2011

Comparable but current financial performance data are available through QHi. Using these data and as reported in Charts 13 and 14, it is evident that for the Wyoming CAHs participating in QHi: 1) their days cash on hand are consistently higher than the average of all other CAHs participating in QHi; 2) their days cash on hand is declining, something that is consistent with all other CAHs participating in QHi; 3) their gross days in A/R have been at or near other CAHs reporting to QHi but they have not reached the national benchmark set by the Flex Monitoring Team of less than 53 days.



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CHART 13:

QHi User Data: Changes in Days Cash on Hand

DAYS CASH ON HAND: WY AND ALL OF QHI

WY (N=8) ALL QHi (N=163)

MONTH

DAYS

350300250200150100

500 2012-09 2012-10 2012-11 2012-12 2013-01 2013-02 2013-03 2013-04 2013-05 2013-06 2013-07 2013-082011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08

CHART 14:

QHi User Data: Changes in Gross Days in Accounts Receivable

GROSS DAYS IN ACCOUNTS RECEIVABLE: WY AND ALL OF QHI


DAYS

MONTH

8070605040302010

0 2012-09 2012-10 2012-11 2012-12 2013-01 2013-02 2013-03 2013-04 2013-05 2013-06 2013-07 2013-082011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08



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CHART 15:

QHi User Data: StaffTurnover

STAFF TURNOVER: WY CAHs AND ALL OF QHI


CHART 16:

QHi User Data: Changes in Benefits as a Percentage of Salary

BENEFITS AS A PERCENTAGE OF SALARY: WY AND ALL OF QHI


Additional core measures being collected and reported in QHi are staff turnover and benefits as a percentage of salary. Looking at the past two years of data (FY12 and FY13) and as reflected in charts 15 and 16, Wyoming CAHs have higher than average levels of staff turnover and lower benefits as a percentage of salary when compared to other QHi users.

MONTH

STAF

F

3.53

2.52

1.51

0.50 2012-09 2012-10 2012-11 2012-12 2013-01 2013-02 2013-03 2013-04 2013-05 2013-06 2013-07 2013-082011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08

35302520151050 2012-09 2012-10 2012-11 2012-12 2013-01 2013-02 2013-03 2013-04 2013-05 2013-06 2013-07 2013-082011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08

MONTH

PERC

ENT


LOOKING AHEAD

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The Wyoming Flex Program has new and ongoing projects planned for FY14, including ongoing support for WCAHN, QHi, EMS and leadership training, and other CAH staff educational opportunities. New for FY14 will be a focus on falls prevention, opportunities for CAHs to engage in Studer training, and statewide EMS planning.

Greatest Challenges“We will be taking a new approach with our work in QHi and will begin focusing on areas of improvement to try and push the needle and better support CAHs as they work to improve the quality of patient care.”

“ The state EMS office has a new set of priorities for Flex that will focus more on education and compliance along with hosting another Leadership Academy.”

FY14 Opportunities“The greatest challenge continues to be identifying services that are of value to a broad base of WCAHN members. Some programs that have historically met broad needs, such as the Healthcare Leadership Training Program, now appear to have run their course. As a result, the WCAHN continually seeks feedbackfrom member CEOs regarding new approaches and services.”

“Trying to meet the uniqueneeds of all the CAHs and the communities

served given the limited resources.”

“Some of our CAHs continue to do well financially while others continue to struggle.Trying to meet the needs of those struggling is particularly difficult because in some instances the needs are well outside the scope and resources of the Flex Program.”

“A focus of the WCAHN is the statewide collaborative project facilitated by the Studer Group. Once in operation, the program will provide Studer’s expertise and tools, as well as facilitate peer group networks and other benefits, to WCAHN members at a deeply discounted rate. It will offer on-site consultation, best practices sharing, and targeted solutions for participating hospitals. As such, it will also represent an entirely new way of leveraging Flex funding to deliver expert consultation across the state in a way that is both broadly applicable and locally targeted. This is a challenging effort because some hospitals are already Studer partners and others are considering the value of an investment with Studer.”

“Operating in a pre-dominantly frontier statewhere distances are great, volunteers are inshort supply, and there are so few resources

to do what needs to be done continuesto be our greatest challenge.”


ADDITIONAL INFORMATION

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For additional information about the Wyoming

Flex Program contact: Michelle Hoffman,

Flex Program Coordinator, Wyoming Department of

Health, Public Health Division, Office of Rural Health

307/777-8902 or [email protected].

This report was created by Rural Health Solutions, Woodbury, Minnesota, through the Wyoming Department of Health, Rural and Frontier Health Division, Office of Rural Health, with a grant from the Health Resources and Services Administration, Office of Rural Health Policy, Grant number H54RH00043.

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