Form 1

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Overview

Flex WP
QI
FOI
PH_EMS
CAH CON
Innovative

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Sheet 1: Flex WP

Medicare Rural Hospital Flexibility (Flex) Grant Program Performance

The following data is associated strictly with the Health Resources and Services Administration's (HRSA) Medicare Rural Hospital Flexability program (Flex) Work Plan.

All measures that follow are requiste work plan information within the five Flex Program Areas: (1) Quality Improvement; (2) Financial and Operations Improvement; (3) Population Health Management and Emergency Medical Service Integration; (4) CAH Conversion; and (5) Innovative Models of Care. These measures are meant to demonstrate ; the number of Flex activities; the number of CAHs participating in Flex funded activities; the number of CAHs that made improvements as a result of the activity; and a break down of Flex funding per activity.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0906-0363. Public reporting burden for this collection of information is estimated to average 70 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10C-03I, Rockville, Maryland, 20857.

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Sheet 2: QI

1.01 CORE PATIENT SAFETY Improvement Outcomes - To Be Answered by all Flex Programs
1.01a	Baseline measure(s) for all CAHs participating in MBQIP Domain 1 Patient Safety Activities during the budget period
1.01b	Outcome measure(s) for all CAHs participating in MBQIP Domain 1 Patient Safety Activities during the budget period
1.01c	Number (#) of CAHs (unduplicated) participating in Core MBQIP Domain 1 Patient Safety activities for HCP / OP-27 during the budget period
1.01d	Number (#) of CAHs (unduplicated) participating in Core MBQIP Domain 1 Patient Safety activities for IMM-2 during the budget period
1.01e	Number (#) of CAHs (unduplicated) participating in Core MBQIP Domain 1 Patient Safety activities that showed improvement on HCP / OP-27 activities during the budget period
1.01f	Number (#) of CAHs (unduplicated) participating in Core MBQIP Domain 1 Patient Safety activities that showed improvement on IMM-2 activities during the budget period
1.01g	Amount ($) of Flex Funds utilized toward Core MBQIP Domain 1 Patient Safety Activity(ies) during the budget period
1.02 CORE PATIENT ENGAGEMENT Improvement Outcomes - To Be Answered by all Flex Programs
1.02a	Baseline measure(s) for all CAHs participating in Core MBQIP Domain 2 Patient Engagement Activities during the budget period
1.02b	Outcome measure(s) for all CAHs participating in Core MBQIP Domain 2 Patient Engagement Activities during the budget period
1.02c	Number (#) of CAHs (unduplicated) participating in Core MBQIP Domain 2 Patient Engagement Improvement Activities during the budget period
1.02d	Number (#) of CAHs (unduplicated) participating in Core MBQIP Domain 2 Patient Engagement activities that improved during the budget period
1.02e	Amount ($) of Flex Funds utilized toward Core MBQIP Domain 2 Patient Engagement Activity(ies) during the budget period
1.03 CORE CARE TRANSITIONS Improvement Outcomes - To Be Answered by all Flex Programs
1.03a	Baseline measure(s) for all CAHs participating in all Core MBQIP Domain 3 Core Care Transition Activities during the budget period
1.03b	Outcome measure(s) for all CAHs participating in Core MBQIP Domain 3 Core Care Transition Activities during the budget period
1.03c	Number (#) of CAHs (unduplicated) participating in Core MBQIP Domain 3 Core Care Transition Activities during the budget period
1.03d	Number (#) of CAHs (unduplicated) participating in Core MBQIP Domain 3 Core Care Transition Activities that improved during the budget period
1.03e	Amount ($) of Flex Funds utilized toward Core MBQIP Domain 3 Care Transition Activity(ies) during the budget period
1.04 CORE Outpatient Improvement Outcomes - To Be Answered by all Flex Programs
1.04a	Baseline measure(s) for all CAHs participating in all Core MBQIP Domain 4 Core Outpatient Activities during the budget period
1.04b	Outcome measure(s) for all CAHs participating in Core MBQIP Domain 4 Core Outpatient Activities during the budget period
1.04c	Number (#) of CAHs (unduplicated) participating in Core MBQIP Domain 4 Core Outpatient Activities during the budget period
1.04d	Number (#) of CAHs (unduplicated) participating in Core MBQIP Domain 4 Core Outpatient Activities that improved during the budget period
1.04e	Amount ($) of Flex Funds utilized toward Core MBQIP Domain 4 Core Outpatient during the budget period
1.05 ADDITIONAL PATIENT SAFETY Improvement Outcomes - To Be Completed if Selected by Flex Programs
1.05a	Baseline measure(s) for all CAHs participating in all Additional MBQIP Domain 1 Patient Safety Improvement Activities during the budget period
1.05b	Outcome measure(s) for all CAHs participating in Additional MBQIP Domain 1 Patient Safety Improvement Activities during the budget period
1.05c	Number (#) of CAHs (unduplicated) participating in Additional MBQIP Domain 1 Patient Safety Improvement Activities during the budget period
1.05d	Number (#) of CAHs (unduplicated) participating in Additional MBQIP Domain 1 Patient Safety Improvement Activities that improved during the budget period
1.05e	Amount ($) of Flex Funds utilized toward Additional MBQIP Domain 1 Patient Safety Improvement Activities during the budget period
1.06 ADDITIONAL CARE TRANSITIONS Discharge Planning Improvement Outcomes - To Be Completed if Selected by Flex Programs
1.06a	Baseline measure(s) for all CAHs participating in all Additional MBQIP Domain 3 Care Transitions Discharge Planning Improvement Activities during the budget period
1.06b	Outcome measure(s) for all CAHs participating in Additional MBQIP Domain 3 Care Transitions Discharge Planning Improvement Activities during the budget period
1.06c	Number (#) of CAHs (unduplicated) participating in Additional MBQIP Domain 3 Care Transitions Discharge Planning Improvement Activities during the budget period
1.06d	Number (#) of CAHs (unduplicated) participating in Additional MBQIP Domain 3 Care Transitions Discharge Planning Improvement Activities that improved during the budget period
1.06e	Amount ($) of Flex Funds utilized toward Additional MBQIP Domain 3 Care Transitions Discharge Planning Improvement Activities during the budget period
1.07 ADDITIONAL CARE TRANSITIONS Medication Reconciliation Improvement Outcomes - To Be Completed if Selected by Flex Programs
1.07a	Baseline measure(s) for all CAHs participating in all Additional MBQIP Domain 3 Care Transitions Medication Reconciliation Improvement Activities during the budget period
1.07b	Outcome measure(s) for all CAHs participating in Additional MBQIP Domain 3 Care Transitions Medication Reconciliation Improvement Activities during the budget period
1.07c	Number (#) of CAHs (unduplicated) participating in Additional MBQIP Domain 3 Care Transitions Medication Reconciliation Improvement Activities during the budget period
1.07d	Number (#) of CAHs (unduplicated) participating in Additional MBQIP Domain 3 Care Transitions Medication Reconciliation Improvement Activities that improved during the budget period
1.07e	Amount ($) of Flex Funds utilized toward Additional MBQIP Domain 3 Care Transitions Medication Reconciliation Improvement Activities during the budget period
1.08 ADDITIONAL OUTPATIENT Improvement Outcomes - To Be Completed if Selected by Flex Programs
1.08a	Baseline measure(s) for all CAHs participating in all Additional MBQIP Domain 4 Outpatient Improvement Activities during the budget period
1.08b	Outcome measure(s) for all CAHs participating in Additional MBQIP Domain 4 Outpatient Improvement Activities during the budget period
1.08c	Number (#) of CAHs (unduplicated) participating in Additional MBQIP Domain 4 Outpatient Improvement Activities during the budget period
1.08d	Number (#) of CAHs (unduplicated) participating in Additional MBQIP Domain 4 Outpatient Improvement Activities that improved during the budget period
1.08e	Amount ($) of Flex Funds utilized toward Additional MBQIP Domain 4 Outpatient Improvement Activities during the budget period
1.09 REPORTING IMPROVEMENTS - To Be Completed if Selected by Flex Programs
1.09a	Baseline measure(s) for all CAHs participating in Reporting Improvement Activities during the budget period
1.09b	Outcome measure(s) for all CAHs participating in Reporting Improvement Activities during the budget period
1.09c	Baseline Number (#) of CAHs reporting on all required Core Measures for budget period
1.09d	Number (#) of CAHs reporting on all required Core Measures by end of the budget period
1.09e	Baseline Number (#) of CAHs reporting on Additional Measures for the budget period
1.09f	Number (#) of CAHs reporting on Additional Measures by end of the budget period
1.09g	Amount ($) of Flex Funds utilized toward 1.09 Activity (ies) during the budget period

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Sheet 3: FOI

2.01 Financial and Operational Improvement - To Be Completed if Selected by Flex Programs
2.01 a	Number Number (#) of CAHs undergoing financial and operational performance assessments during the budget period
2.01b	Amount ($) of Flex Funds utilized toward Activity 2.01 during the budget period
2.02 In-Depth Assessments - To Be Completed if Selected by Flex Programs
2.02a	Number (#) of CAHs participating in an in-depth assessment during the budget period
2.02b	Number (#) of financial indicators identified for improvement during the budget period
2.02c	Number (#) of financial indicators that improved during the budget period
2.02d	Amount ($) of Flex Funds utilized toward Activity 2.02 during the budget period
2.03 Revenue Cycle Management - To Be Completed if Selected by Flex Programs
2.03a	Baseline measure(s) for all CAHs participating in Revenue Cycle Management Activities during the budget period
2.03b	Outcome measure(s) for all CAHs participating in Revenue Cycle Management Activities during the budget period
2.03c	Number (#) of CAHs that used Flex funding for updating their chargemaster during the budget period
2.03d	Number (#) of CAHs improved days in accounts receivable during the budget period
2.03e	Number (#) of CAHs improved change in revenue during the budget period
2.03f	Number (#) of CAHs improved change in number of claims denied during the budget period
2.03g	Number (#) of CAHS that implemented a Revenue Cycle Management Activity during the budget period
2.03h	Number (#) of CAHs improved in Revenue Cycle Management Activities during the budget period
2.03i	Amount ($) of Flex Funds utilized toward Activity 2.03 during the budget period
2.04 Operational Improvements -To Be Completed if Selected by Flex Programs
2.04a	Baseline measure(s) for all CAHs participating in Operational Improvement Activities during the budget period
2.04b	Outcome measure(s) for all CAHs participating in Operational Improvement Activities during the budget period
2.04c	Number (#) of CAHS that implemented an Operational Improvement Activity during the budget period
2.04d	Number (#) of CAHs improved in Operational Improvement Activities during the budget period
2.04e	Number (#) of CAHs that implemented/participated in an activity related to improving hospital departments during the budget period
2.04f	Number (#) of CAHs that implemented/participated in an activity related to improving hospital services this budget period
2.04g	Number (#) of CAHs that implemented/participated in an activity related to improving hospital processes this budget period
2.04h	Number (#) of CAHs that met or exceeded revenue during the budget period
2.04i	Number (#) of CAHs that improved change in staff time during the budget period
2.04j	Number (#) of CAHs that improved change in patient time during the budget period
2.04k	Number (#) of CAHs that improved change in market share during the budget period
2.04l	Number (#) of CAHs that improved percent of all patients in the correct level of care from the time of admission during the budget period
2.04m	Number (#) of financial and/or operational improvement Networks during the budget period
2.04n	Number (#) of CAHs participating in these networks during the budget period
2.04o	Number (#) of seminars & workshops sponsored during the budget period
2.04p	Number (#) of CAHs attending each seminar &/or workshop during the budget period
2.04q	Number (#) of total participants in each seminar &/or workshop during the budget period
2.04r	Total cost ($) of seminars & workshops during the budget period
2.04s	Number (#) of CAHs completing the Lean readiness assessments during the budget period
2.04t	Number (#) of CAHs participating in a Lean collaborative during the budget period
2.04u	Number (#) of CAHs at which Lean initiatives were implemented during the budget period
2.04v	Number (#) of CAHs participating in the coding training during the budget period
2.04w	Number (#) of CAHs actively participating in CAH governance events during the budget period
2.04x	Number (#) of CAHs developing financial components in their board education programs during the budget period
2.04y	Number (#) of CAHs participating in financial education workshops and collaboratives during the budget period
2.04z	Amount ($) of Flex Funds utilized toward Operational Improvements during the budget period

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Sheet 4: PH_EMS

3.01	Statewide CAH Population Health Management Needs Assessment -To Be Completed If Selected By Flex Programs
3.01a	Amount ($) of Flex Funds utilized toward Activity 3.01 during the budget period
3.02	Hospital Community Health Needs Assessments and Improvement --To Be Completed If Selected By Flex Programs
3.02a	Baseline measure(s) for all CAHs participating in Hospital Community Health Needs Assessments and Improvement Activities during the budget period
3.02b	Outcome measure(s) for all CAHs participating in Hospital Community Health Needs Assessments and Improvement Activities during the budget period
3.02c	Number (#) of CAHs participating in a Hospital Community Health Needs Assessment and Improvement Activity during the budget period
3.02d	Number (#) of CAHs participating in a Hospital Community Health Needs Assessment and Improvement Activity that demonstrated improvement during the budget period
3.02e	Amount ($) of Flex Funds utilized toward Activity 3.02 during the budget period
3.03	Community-level Rural EMS System Assessment --To Be Completed If Selected By Flex Programs
3.03a	Number (#) of CAHs participating in an Community-level Rural EMS System Assessment during the budget period
3.03b	Baseline measure(s) for all CAHs participating in Community-level Rural EMS System Assessment during the budget period
3.03c	Outcome measure(s) for all CAHs participating in Community-level Rural EMS System Assessment during the budget period
3.03d	Number (#) of best practices shared during the budget period
3.03e	Number (#) of communties reached as a result of improvement activity during the budget period
3.03f	Number (#) of stakeholder groups engaged as a result of improvement activity during the budget period
3.03g	Number (#) of CAHs participating in Community-level Rural EMS System activities during the budget period
3.03h	Number (#) of CAHs participating in Community-level Rural EMS System activities that improved during the budget period
3.03i	Amount ($) of Flex Funds utilized toward Activity 3.03 during the budget period
3.04	Population Health Improvement Activity -To Be Completed If Selected By Flex Programs
3.04a	Baseline measure(s) for all CAHs participating in Population Health Improvement Activities during the budget period
3.04b	Outcome measure(s) for all CAHs participating in Population Health Improvement Activities during the budget period
3.04c	Number (#) of CAHs participating in a Population Health Improvement Activity during the budget period
3.04d	Number (#) of CAHs that improved in a Population Health Improvement Activity during the budget period
3.04e	Amount ($) of Flex Funds utilized toward Activity 3.04 during this budget period
3.05	Improve Time Critical Diagnoses EMS System Capacity -To Be Completed If Selected By Flex Programs
3.05a	Baseline measure(s) for all CAHs participating in Improve Time Critical Diagnoses EMS System Capacity Activities during the budget period
3.05b	Outcome measure(s) for all CAHs participating in Improve Time Critical Diagnoses EMS System Capacity Activities during the budget period
3.05c	Number (#) of CAHs participating in Improve Time Critical Diagnoses EMS System Capacity Activities during the budget period
3.05d	Number (#) of EMS entities participating in Improve Time Critical Diagnoses EMS System Capacity Activities during the budget period
3.05e	Number (#) of CAHs participating in Improve Time Critical Diagnoses EMS System Capacity Activities that improved during the budget period
3.05f	Number (#) of EMS entities participating in Improve Time Critical Diagnoses EMS System Capacity Activities that improved during the budget period
3.05g	Amount ($) of Flex Funds utilized toward Improve Time Critical Diagnoses EMS System Capacity Activities during the budget period
3.05h	Baseline of EMS agencies with operational TCD system PI committee
	Added # of EMS agencies with operational TCD system PI committee
3.05i	Baseline EMS agencies implementing strategies to address resource and work force needs;
	Added # EMS agencies implementing strategies to address resource and work force needs
3.05j	Baseline # of EMS trained on STEMI, Stroke, and Trauma
	Added # of EMS trained on STEMI, Stroke, and Trauma
3.05k	Baseline # of EMS agencies using AHA Lifeline Guidelines for STEMI and stroke
	Added # of EMS agencies using AHA Lifeline Guidelines for STEMI and stroke
3.05l	Baseline # of EMS agencies using CDC guidelines for field triage of injured patients (trauma) all ages
	Added # of of EMS agencies using CDC guidelines for field triage of injured patients (trauma) all ages
3.05m	Baseline # of EMS agencies with ED dispatch;
	Added # of of EMS agencies with ED Dispatch;
3.05n	Baseline # of EMS agencies functioning as integrated systems of emergency care;
	Added # of EMS agencies functioning as integrated systems of emergency care
3.05o	Baseline # of EMS agencies with improved performance on key TCD measures (e.g., D2B of </= 90 minutes);
	Added # of of EMS agencies with improved performance on key TCD measures (e.g., D2B of </= 90 minutes);
3.05p	Added # of EMS agencies with improved financial and quality performance
3.05q	Improved EMS systems performance locally and regionally.
3.06	Improve EMS Capacity and Operational Activity -To Be Completed If Selected By Flex Programs
3.06a	Baseline measure(s) for all CAHs participating in Improve EMS Capacity and Operational Activities during the budget period
3.06b	Outcome measure(s) for all CAHs participating in Improve EMS Capacity and Operational Activities during the budget period
3.06c	Number (#) of CAHs participating in Improve EMS Capacity and Operational Activities during the budget period
3.06d	Number (#) of EMS entities participating in Improve EMS Capacity and Operational Activities during the budget period
3.06e	Number (#) of CAHs participating in Improve EMS Capacity and Operational Activities that improved for the budget period
3.06f	Number (#) of EMS entities participating in Improve EMS Capacity and Operational Activities that improved for the budget period
3.06g	Amount ($) of Flex Funds utilized toward Improve EMS Capacity and Operational Activities during this budget period
3.06h	Baseline # of EMS agencies billing third party payers/patients;
	Added # of EMS agencies billing third party payers/patients
3.06i	Baseline # of EMS agencies using patient billing and financial data for PI;
	Added # of EMS agencies billing third party payers/patients
3.06j	Baseline # of EMS agencies with quality improvement protocols and processes;
	Added # of EMS agencies with quality improvement protocols and processes;
3.06k	Baseline # of EMS agencies using quality data;
	Added # of EMS agencies using quality data;
3.06l	Baseline # of local/regional EMS systems of care in which participants meet regularly to review data on quality and system performance;
	Added # of local/regional EMS systems of care in which participants meet regularly to review data on quality and system performance;
3.06m	Baseline # of EMS agencies with performance improvement plans;
	Added # of EMS agencies with performance improvement plans;

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Sheet 5: CAH CON

4.01	Designation of CAHs in the state -To Be Completed If Selected By Flex Programs
4.01a	Number (#) of hospitals requesting and receiving assistance in conversion to CAH status during the budget period
4.01b	Number (#) of hospitals converted to CAH status during the budget period
4.01c	Number (#) of hospitals unsuccessful in their attempt to convert to CAH status during the budget period
4.01d	Amount ($) of Flex Funds utilized toward Activity 4.01 during this budget period

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Sheet 6: Innovative

5.01	INTEGRATION OF INNOVATIVE MODELS of CARE -To Be Completed If Selected By Flex Programs
5.01a	Baseline measure(s) for all CAHs participating in Integration of Innovative Models of Care Activities during the budget period
5.01b	Outcome measure(s) for all CAHs participating in Integration of Innovative Models of Care Activities during the budget period
5.01c	Number (#) of CAHs participating in Integration of Innovative Models of Care Activities for the budget period
5.01d	Number (#) of CAHs participating in Integration of Innovative Models of Care Activities that improved during the budget period
5.01e	Amount ($) of Flex Funds utilized toward Integration of Innovative Models of Care Activities during the budget period