Raising the Standards – Providing Quality Healthcare in Rural North Dakota
By Jessica Rosencrans on
Lifestyles can look very different based on where you live. Driving through rush hour to get to and from work is a daily reality for many people who live in urban areas, while the same commute to work can take rural residents past fields of wheat, pastureland, or the scattered farmstead. Careers that are bountiful in rural locations dissipate as the population density increases.
But one facet of life that shouldn't differ based on where you live is the quality of healthcare available. Federal grants, such as the Medicare Rural Hospital Flexibility Grant (Flex) Program and the Small Hospital Improvement Program (SHIP), help sustain the quality of care provided in rural hospitals.
Flex is a national program whose purpose is to assist rural hospitals and improve access to health services in rural communities. Quality Improvement (QI) is just one of multiple areas of focus for Flex. It also financially supports the financial/operational improvement for both Critical Access Hospitals (CAHs) and Rural Health Clinics (RHCs) and provides support for rural EMS networking and CAH designation.
The North Dakota Flex Program is housed at the Center for Rural Health (CRH), located within the University of North Dakota School of Medicine & Health Sciences. Recently, the Flex Program celebrated its 25th anniversary of aiding North Dakota healthcare providers, communities, and residents.
The Power of Collaboration
Jody Ward, grant program director at CRH and principal investigator of Flex, shares that in her 17 years of working with the Flex Program, the North Dakota CAH Quality Network has been one of the most successful implementations.
"By using Flex dollars, the North Dakota CAH Quality Network supports North Dakota hospitals, without charging for membership, to provide technical assistance to ensure they are able to collect data specific to CAHs on quality measures," Ward says. "Flex staff works with each hospital to make sure they are able to have programming and activities around capturing patient safety information."
A CAH is a specific designation of hospital provided by the Centers for Medicare & Medicaid Services. Among other qualifications, a CAH must have 20 or fewer inpatient beds and be located more than 35 miles from another hospital. North Dakota currently has 37 CAHs.
This collaborative network has transformed the relationship among CAHs in the state. With better channels of communication, hospitals can share resources, strategies for improvement, and ultimately provide a higher level of care to their patients.
Each year, a list of top performing 100 CAHs in the nation is released by the Chartis Center for Rural Health. Based on how hospitals manage risk, achieve higher quality, secure better outcomes, increase patient satisfaction, and operate at a lower cost than their peers, this list represents a significant achievement for rural facilities.
"North Dakota has consistently had multiple representatives on that list," Ward said proudly. "That speaks to our success in financial/operational improvement, QI, and patient safety measures across the state."
The North Dakota CAH Quality Network is so successful that the structure was replicated for the North Dakota Rural Health Clinic (RHC) Network.
Impactful Programming
The Flex Program also facilitates grant funding available to North Dakota CAHs. Mountrail County Medical Center (MCMC), located in Stanley, North Dakota, is one CAH that has received Flex funding for various projects.
The funds they give us allow us to complete needed quality projects that we could not afford on our own.
Stephanie Everett, CEO of MCMC, explains that, "The funds they give us allow us to complete needed quality projects that we could not afford on our own, due to budget constraints. It has allowed us to internally complete 340B audits, financial and operational assessments, and chart audits. This in hand helps us improve our services to our community."
Northwood Deaconess Health Center, located in Northwood, North Dakota, has also benefited from the Flex Program. "In rural healthcare, resources and financial capacity can be very limited, and Flex has allowed us access to resources that we likely wouldn't have been able to use otherwise," says Brock Sherva, CEO of Northwood Deaconess Health Center.
"This program has been vital for us in a couple of ways. The Flex Program has provided funding to cover registration and travel expenses for rural health conferences that we wouldn't have been able to attend. This has allowed us to collaborate with other rural health professionals and learn best practices from industry experts."
With Flex's support, the
CAH was able to host a presentation for its staff by
Brian Lee, a speaker from Custom Learning
Systems. As part of this experience, staff at
Northwood Deaconess Health Center reviewed results from
their Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS), a survey of patient's
perspectives of hospital care.
"This presentation focused on building a culture of compassion and healing by interpreting feedback from HCAHPS scores," shared Sherva. "Since the seminar, we've moved forward with Custom Learning Systems and become a Five Star Facility of Choice. Without Flex, we wouldn't have been exposed to this program."
Another metric that Flex has been working with rural hospitals on is the Antibiotic Stewardship Program, which focuses on responsible prescribing of antibiotics, tracking antibiotic resistance, and educational training. As a way to recognize facilities that have effective Antibiotic Stewardship Programs, Flex has presented an award at the Dakota Conference on Rural and Public Health to a North Dakota healthcare provider that has successfully implemented their program.
Supporting Rural Communities
Alongside Flex, another federal effort is supporting rural hospitals: the SHIP Program. SHIP is a companion program to Flex, where it supports Flex's programming in quality and financial/operational improvement. SHIP, like Flex, is funded by the Federal Office of Rural Health Policy, under the Health Resources and Services Administration.
The SHIP Program supports eligible hospitals in meeting value-based payment and care goals for their respective organizations, through purchases of hardware, software, and training. SHIP also enables small rural hospitals to become or join accountable care organizations (ACOs); to participate in shared savings programs; and to purchase health information technology, equipment, and/or training to comply with QI activities, such as advancing patient care information, promoting interoperability, and payment bundling.
"Where Flex's scope is limited to CAHs and CAH-owned RHCs," says Nicole Threadgold, grant program director at CRH and principal investigator of SHIP. "SHIP is open to all small rural hospitals – hospitals that have 49 beds or less. North Dakota is unique in that there aren't any small rural hospitals in the state."
Of North Dakota's 37 CAHs, SHIP aided 15 in value-based purchasing; 23 in activities regarding ACOs or shared savings investments; and 15 in payment bundling or Prospective Payment System investment activities in the last completed grant year.
With
assistance from SHIP, MCMC was able to incorporate AVEL
eCare in its emergency room. The addition of new
technology and telemedicine in a rural setting, where
every moment counts, can make a big impact.
"SHIP is an important program," Threadgold says. "For small rural hospitals, expenses such as hardware, software, and training can sometimes be difficult to budget when there are other priorities. SHIP funding allows for these important items to be supported in order for a CAH to continue advancing in these areas."
Sustaining Excellence in Rural Health
What we are doing in helping these facilities to better meet requirements and standards, I like to think is saving lives and protecting patients who enter clinics and health systems.
Over the past 25 years, the Flex Program has impacted countless rural residents through its programming. "What we are doing in helping these facilities to better meet requirements and standards, I like to think is saving lives and protecting patients who enter clinics and health systems," Ward said. "I am so, so proud of the program we have. Not every Flex Program in the nation looks the same. And when I came on deck, I had to learn from a few other programs that were excelling. So, although we look different, we've remained strong."
Without the Flex Program's support, care in rural North Dakota could look very different.
"Small Critical Access Hospitals would not be able to do the quality projects such as the ones MCMC has been able to do without the help of funds from the Flex Program," Everett emphasized. "We are so grateful for the opportunities presented to us."
is the communication specialist with the Center for Rural
Health at the University of North Dakota School of
Medicine & Health Sciences in Grand Forks.
