Form 1 SRHT Application Form

SMALL RURAL HOSPITAL TRANSITIONS (SRHT) PROJECT

Application for Technical Assistance (TA)

Application period: XXXXXXX 2016 – XXXXXXX, 2016

closes mid-night on XXXXXXX, XXXXXXX 2016.

To successfully submit a full application, hospitals must complete both the online application and the SurveyMonkey Assessment.

Applications must be submitted online, and are not accepted through email and fax. Use this document to prepare for the online application. The online application form does not allow you to save your progress. Please review the form to ensure you have all of the information before submitting it. Do not leave any question blank as it will impact your overall score. Both CAHs and PPS hospitals should complete all questions in the online application and SurveyMonkey assessment.

Online Application Questions

Part 1 of Online Application: General Information

This section requests information that is required to submit your hospital’s application. This section is not scored.

1. Hospital Name

2. Address

3. City

4. State

5. Zip Code

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 0915-XXXX. Public reporting burden for this collection of information is estimated to average .50 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 14N39, Rockville, Maryland, 20857.

6. County / Parish

7. CEO Name

8. CEO Direct Phone Number

9. CEO E-mail Address

10. Confirm CEO Email Address

11. Administrative Assistant Name

12. Administration Phone Number

13. Administrative Assistant E-mail Address

14. Hospital designation – PPS / CAH / IHS

15. Number of staffed beds as per the most recently filed Medicare Cost Report

16. Ownership

17. Are you affiliated with a hospital system?

• If yes, which system is your hospital affiliated with?

18. Is your hospital a member of a rural health network?

• If yes, what is the name of the network?

19. Is your hospital a member of a purchasing group or part of a state program network such as CAH or quality?

    • If yes, what is the name of the network and/or purchasing group?

20. Does your hospital operate under a management company?

• If yes, what is the name of the management company?

21. Have you previously received onsite consulting services from the Rural Hospital Performance Improvement Project (RHPI)? Yes/No/DK (don’t know)

22. Are you a direct recipient of a Center for Medicare and Medicaid Innovation (CMMI) grant?

23. Is your hospital a member of a system that is a recipient of a Center for Medicare and Medicaid Innovation (CMMI) grant?

24. Is your hospital currently receiving technical assistance from FORHP or from other Federal programs for activities such as a financial operational assessments or creating quality through patient care and operations?

    • If yes, please explain

25. Choose the onsite consultation project, according to your need:

• Financial Operational Assessment

• Quality of Care/Transition of Care Project

Part 2 of Online Application: Additional Information for Application Scoring and Ranking of Hospitals

This section will be used to score and rank your hospital’s application in the selection process. Do not leave any question blank as it will impact your overall score. Both CAHs and PPS hospitals should respond to this section.

1. Regardless if you are a CAH or PPS hospital, indicate if you participate in the following programs:

   1. Small Rural Hospital Improvement Grant Program (SHIP)

2. State Medicare Rural Hospital Flexibility (Flex) Program (trainings, sub-contracts that are supported by Flex)

3. Small Health Care Provider Quality Program

• If yes, please provide network name and year funded and whether you were the lead applicant or a network participant only.

1. Rural Health Network Development Program

• If yes, please provide network name and year funded and whether you were the lead applicant or a network participant only.

1. Please list any other Federal Office of Rural Health Policy (FORHP) programs or projects you participate in. Please provide grantee /network name and year funded and whether you were the lead applicant or a network participant only.

2. Is your hospital actively participating in an Accountable Care Organization (ACO)?

• If no, are you actively planning and working to become part of an ACO?

3. Is your hospital actively participating in a shared savings program?

• If no, are you actively planning and working to participate to in a shared savings program?

4. Is your hospital actively participating in a Patient Centered Medical Home (PCMH)?

• If no, are you actively planning and working to become part of a PCMH?

5. Enter the following Key Performance Indicators (KPIs) with most recent data for your hospital. There is not a correct answer.

Net Patient Revenue Total Operating Revenue Total Operating Expenses

Days in Net Accounts Receivable Days in Gross Accounts Receivable Days Cash on Hand

Total Margin (%) Operating Margin (%) Net Income

6. Do you presently have a strategic plan in place?

• If yes, describe the dashboard you use (for example, Balanced Scorecard or other model) to monitor progress on your hospital’s strategic goals and how this information is shared in your organization.

7. Describe the type of data you currently track regarding hospital readmissions and identify the current values.

8. Have you instituted a post discharge patient follow-up process?

• If yes, are you tracking and quantifying the outcome?

9. Describe what you are currently doing to address population health and chronic disease management?

10. What have you done to this point to prepare for the transition to a value-based payment system?

11. How do you anticipate this project assisting your hospital in preparing for the new health care environment?

12. What are your hospital’s present strengths that will assist you in participating in this project and implementing the consultant’s recommendations to move towards future payment and delivery models?

13. Please list resources and training needs required for your hospital’s success in the newly emerging system of health care delivery and payment.

Part 3 Participation Requirements and CEO Verification Statements

Participation Requirements

Hospitals should be able to meet and complete the below requirements in order to participate in a SRHT consultation project.

1. The CEO will serve as the project lead, facilitating the onsite consultations with the consultant. As the project lead, the CEO must be actively involved and fully engaged in all aspects of the project. The CEO may not designate any other person to fulfill this participation requirement. Additional requirements include the following:

   1. Indicating congruence between the hospital’s performance needs and SRHT available services.

   2. Obligating and committing necessary time to support the project to include adequate time with the executive and management teams and appropriate hospital staff.

   3. Building support for the project with the Board of Directors and hospital and medical staff.

   4. Utilizing recommended resources to prepare management team and hospital staff for onsite consultation.

   5. Scheduling and holding the mutually agreed upon dates for onsite consultations. Once secured, onsite dates may not be rescheduled.

   6. Developing best practice recommendations with the consultant that support process improvement that sustain gains post-project.

   7. Developing action plan with the consultant, executive and management teams to implement consultant’s best practice recommendations.

   8. Identifying and developing strategies with consultant that support the hospital in moving towards the adoption of new payment and care delivery models of the future.

   9. Finalizing the final report with the consultant and RHI staff

10. Providing project outcome data resulting from the consultation with RHI staff in post-project follow up assessment.

11. Sharing successes and lessons learned with peer hospitals.

12. Preparing the hospital for the new healthcare environment

2. The hospital should not have any pending projects or anticipated issues that would hinder the consultation process to include, but not limited to, the following examples:

   1. If the hospital is affiliated with a system, then the system must support the hospital project by providing all necessary data to complete and submit the data request, which may include audited financial reports, within the SRHT timeline.

   2. If the hospital is currently working on a large project such as a HIT deployment, then executive team must ensure that management and staff time has been appropriately committed to fully support the SRHT project activities.

Hospital Readiness Requirements and Project Expectations

Selected hospitals must be able to take immediate action steps to meet project expectations. Hospitals should be ready to:

1. Initiate and complete the project as planned in the scope of work (SOW), adhering to all SOW timelines.

2. Submit the data request by the deadline to initiate the project

3. Implement consultant’s recommendations

4. Complete a post-project interview and provide post-project values to demonstrate measureable outcomes

5. Build upon technical assistance provided through the SRHT Project with a commitment and goal to work towards participating in a system that adds value.

CEO Verification Statements

1. I have read and am in agreement with the participation requirements. I understand that the participation requirements are the basic necessities that my hospital must be willing and able to do to apply for SRHT services.

2. I’m verifying that our hospital meets readiness requirements, and we agree to meet project expectations by completing the participation requirements. I understand that consultation projects must be initiated no later than January 2016 and be completed by July 2016. I also understand that hospitals unable to meet readiness requirements shall be placed back in queue and the support shall be directed to the next hospital.

3. I’m verifying that our hospital is not currently receiving technical support for activities that are same as / similar to those provided through SRHT project.

4. I verify that that our hospital has 49 or less staffed beds as per the most recently filed Medicare Cost Report.

CEO online signature is required to submit the application

Part 4 Confirmation Page: Online Application Receipt

You will receive a confirmation that your online application was successfully submitted. For your convenience, a PDF of the online application will be forwarded to the CEO Email address. You will need Adobe Reader to view this PDF.

Hospitals must also complete the SurveyMonkey assessment to submit the full application. A link to SurveyMonkey assessment will be provided on the confirmation page.

The PE self-assessment questionnaire provided through SurveyMonkey is used in conjunction with the online application to score and rank hospitals. The scores from both sections are totaled. The information obtained from questionnaire provides insight concerning your hospital’s current culture. To learn more about the questionnaire, refer to the attachments and Appendix F in the Critical Access Hospital Blueprint for Performance Excellence.

If you have any questions, please contact Bethany Adams at (859) 806- 2940 or [email protected].

The Small Rural Hospital Transition (SRHT) Project is supported by Contract Number HHSH250201400023C from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Federal Office of Rural Health Policy.