PREAMBLE
Developing strategic objectives for the Medicare Rural Hospital Flexibility Program (Flex) should include at least three content areas. Clearly, measuring the impact of the Flex program and improving its performance at community, State and Federal levels must be addressed. Critical Access Hospitals (CAH) are equally important as the program works to sustain and improve mission accomplishment of CAHs and networking arrangements developed with Flex funding. The natural product of these two areas is strengthening and improving the rural healthcare infrastructure, which is the overarching purpose of the Flex program. Note that integrating EMS is a component of all three areas.

Partnering and collaboration at the Federal, State and community levels enable the accomplishment of this healthcare strategy in rural America. Resources available within the program for influencing the use of available funds for activities consistent with the strategic plan include: the Program Guide; Objective Review Committee reports; funding decisions and special conditions of grant awards; publications; the Technical Assistance and Services Center; questions asked and feedback provided in the evaluation process; and public presentations and workshops in various formats and forums across the nation.

Program vision statement:
The Flex Program is an ideal vehicle for sustaining access to appropriate healthcare services of high quality in rural America. It will facilitate the development and support of community-based collaborative rural delivery systems in all grantee states through conversion of hospitals to critical access status, rural healthcare network development and EMS integration. The Program shall maintain its adaptability to varying conditions in each State.

Program mission:
Consistent with the vision statement, Flex will help sustain the rural healthcare infrastructure by strengthening CAHs and eligible facilities and helping them operate as the hub of a collaborative delivery system in those communities where they exist. By applying the components of Flex [State Rural Health Plan (SRHP), CAHs, networks, Quality Improvement and EMS integration initiatives], the Program can foster the growth of rural collaborative healthcare systems across the continuum of care at the community level with appropriate external relationships for referral and support.

Program goals:

• Facilitate conversion of suitable eligible facilities to critical access status
• Integrate rural EMS operations into Flex-related rural healthcare networks
• Foster development of rural healthcare networks associated with CAHs
• Foster rural healthcare workforce development, recruitment and retention
• Improve access to services that meet identified local needs
• Improve quality of services through implementing measurable objectives
• Improve economic viability of the rural healthcare infrastructure
• Engage rural communities in healthcare decision-making and system development
• Demonstrate improvement of the health status of the community using measurable evaluation tools over the next decade
• Using evaluation information, continuously improve program operations at Federal, State and local levels
• Disseminate information to further Program objectives
• Provide technical assistance which fosters achievement of Program objectives
• Continuously enhance the capabilities of State grantees to further Program objectives

(NOTE: objectives 1, 2 and 3 directly implement the legislative requirements of the program)

Objective 1: Facilitate appropriate conversion of small rural hospitals to critical access status in accordance with current statute.
ACTIVITIES: Continue to support funding for conversion activities.
MEASURE: The number of hospitals assisted in evaluating the effects of conversion to critical access status; the number of hospitals converted to critical access status; proportion of eligible facilities converted

Objective 2: Facilitate development of all types of effective formal networks and informal collaborations. This would include local "vertical" community-based networks across the continuum of care to address access, service, cost and quality in addition to horizontal hospital networks.
ACTIVITIES: revise guide, review applications and relate funding to performance, assess effectiveness of implementation at both State and Program levels.
MEASURES: resources budgeted; effectiveness of State program as indicated by numbers of community-based vertical networks and horizontal CAH networks.

Objective 3: Promote integration of rural EMS operations into local networks and other activities designed to strengthen rural EMS.
ACTIVITIES: design guidance to encourage funding for EMS integration, quality improvement and financial sustainability through improved business operations.
MEASURES: Resources budgeted in applications; effectiveness as indicated by the number of EMS operations formally integrated and informally collaborating with CAHs and CAH-eligible facilities.

(NOTE: Objectives 4 through 7 implement the legislative intent to sustain access to high quality care for rural Medicare beneficiaries)

Objective 4: Require performance improvement programs (including clinical quality and patient safety) at the hospital and community levels as a State grantee function; encourage chronic disease management programs as a component of this function.
ACTIVITIES: design guidance, perform reviews of applications and link funding to effectiveness.
MEASURES: resources budgeted; number of technical assistance projects performed; effectiveness as indicated by numbers of active programs in the State. The ultimate measures over several years will be improved performance, quality and safety measures as compared to national statistics and improving community health status.

Objective 5: Encourage community engagement/outreach as an integral program function to help support utilization and financial viability of CAHs and eligible facilities.
ACTIVITIES: Articulate expectations in guidance; evaluate applications and link funding to performance.
MEASURES: resources budgeted; effectiveness as indicated by technical assistance efforts performed. The ultimate measure will be a decrease in out-migration of community members for locally available services.

Objective 6: Encourage workforce development (skill building, competence assessment, recruiting, retention, e.g.) as a State grantee function.
ACTIVITIES: Articulate expectations in guidance; evaluate applications and link funding to performance.
MEASURES: resources budgeted, technical assistance activities undertaken, recruitment and retention programs implemented by State.

Objective 7: Help improve financial performance of critical access hospitals.
ACTIVITIES: Objectives 1 through 6 above.
MEASURES: Through the National evaluation project, measure CAH operating margins, equity ratios and other relevant financial performance indicators.

(NOTE: Objectives 8 and 9 help assure that program capacity is maintained to achieve legislative requirements and intent)

Objective 8: Help sustain State capacity to accomplish Flex goals in a manner most appropriate for each State.
ACTIVITIES: Technical assistance via TASC; support of appropriate staffing at grantee level.
MEASURES: cumulative of effectiveness measures in objectives 1 - 6.

Objective 9: Monitor and improve effectiveness and efficiency of grantees and contractors associated with the Flex program.
ACTIVITIES: External evaluation of TASC; stakeholder survey of applicability and utility of Evaluation program; subjective assessment of impact of evaluation program; quality and value of publications by evaluators.
MEASURES: documented output of above activities.

Dec. 4, 2003.