Critical Access Hospitals Quality Care in Rural West Virginia

Critical Access HospitalsCritical Access Hospitals

Quality Care in Rural West VirginiaQuality Care in Rural West Virginia

IntroductionIntroduction

Changes to the Rural Changes to the Rural Healthcare SystemHealthcare System

• Approximately 20% of the nation’s Approximately 20% of the nation’s population lives in areas where population lives in areas where education, economic services, education, economic services, transportation, and health services transportation, and health services are sparse or nonexistent. are sparse or nonexistent.


• The rural healthcare system is changing The rural healthcare system is changing due to changes in healthcare financing, due to changes in healthcare financing, new technology, and the clustering of new technology, and the clustering of health services into systems and health services into systems and networks.networks.– Fee for Service Payment replaced by Fee for Service Payment replaced by

managed caremanaged care


• Increase in the development of networks Increase in the development of networks and systems v. private practiceand systems v. private practice

• Rural America has 20% of the nation’s Rural America has 20% of the nation’s population, but less than 11% of it’s population, but less than 11% of it’s physiciansphysicians– Rural clinician often described as “another Rural clinician often described as “another

breed” willing to cope with professional breed” willing to cope with professional isolation and independence in rather isolation and independence in rather unusual cases.unusual cases.


• Rural residents are more often Rural residents are more often uninsured than urban residents, and uninsured than urban residents, and more likely to report themselves in fair more likely to report themselves in fair or poor health.or poor health.

• 1990’s Policy began to focus on 1990’s Policy began to focus on resource disparities as well as payment resource disparities as well as payment policies for Medicare beneficiaries as policies for Medicare beneficiaries as well as the supply of healthcare well as the supply of healthcare professionals. professionals.


• Starting in the 1980’s rural hospitals Starting in the 1980’s rural hospitals began to close their doors.began to close their doors.– Most vulnerable hospitals had 25 beds or Most vulnerable hospitals had 25 beds or

less and were located more than 35 miles less and were located more than 35 miles from the next hospitalfrom the next hospital

• Some Rural hospitals were able to Some Rural hospitals were able to survive due to a change in survive due to a change in discriminatory Medicare Payment discriminatory Medicare Payment Policies.Policies.

What is a Critical Access What is a Critical Access Hospital (CAH)?Hospital (CAH)?

WV CAH DefinitionWV CAH Definition

• Currently Licensed FacilityCurrently Licensed Facility• Annual Average Service Limit of 96 Annual Average Service Limit of 96

hours of in-patient service per pt. hours of in-patient service per pt. excluding observation and swing bedexcluding observation and swing bed

• Facility limited to 25 beds (swing or Facility limited to 25 beds (swing or acute)/ May have Distinct Part Unit acute)/ May have Distinct Part Unit (DPU) such as LTC(DPU) such as LTC

• WV Medicare and Medicaid payment WV Medicare and Medicaid payment received is cost based reimbursementreceived is cost based reimbursement

WV CAH Definition Cont.WV CAH Definition Cont.

• Rural Health Network: Rural Health Network: – At least 1 CAH and 1 affiliate hospital: At least 1 CAH and 1 affiliate hospital:

agreements maintained with network agreements maintained with network hospital may include: hospital may include: • Referral and Transfer, CommunicationsReferral and Transfer, Communications• Agreement with network hospitalAgreement with network hospital• PRO or equivalent for: Credentialing, PRO or equivalent for: Credentialing,

Quality Assurance, TransportationQuality Assurance, Transportation

WV CAH Definition Cont.WV CAH Definition Cont.

• Flexible Aspects of the Program Flexible Aspects of the Program Include:Include:– Services included (IP, OP, ER, Lab, Services included (IP, OP, ER, Lab,

Radiology, DPU, etc…)Radiology, DPU, etc…)– Emergency ServicesEmergency Services– Medical StaffMedical Staff– Nursing StaffNursing Staff– Hours of OperationHours of Operation

How CAHs were FoundedHow CAHs were Founded

• In February 1998, WV became the In February 1998, WV became the first state in the nation to receive first state in the nation to receive approval from the Centers for approval from the Centers for Medicare and Medicaid Services to Medicare and Medicaid Services to implement the Medicare Rural implement the Medicare Rural Hospital Flexibility Program.Hospital Flexibility Program.

How CAHs were FoundedHow CAHs were Founded

• The WV Rural Hospital Flexibility The WV Rural Hospital Flexibility Program (WVRHFP) resulted from a Program (WVRHFP) resulted from a national initiative to strengthen rural national initiative to strengthen rural healthcare through:healthcare through:– Allowing small hospitals the ability to Allowing small hospitals the ability to

reconfigurereconfigure– Offering cost based reimbursementOffering cost based reimbursement– Encouraging the development of rural health Encouraging the development of rural health

networksnetworks– Offering grants to rural hospitals to Offering grants to rural hospitals to

strengthen their infrastructurestrengthen their infrastructure

CAHs are Different than CAHs are Different than Other Hospitals…Other Hospitals…

• To be eligible as a CAH, a hospital must:To be eligible as a CAH, a hospital must:– Be a current participating Medicare Hospital Be a current participating Medicare Hospital

oror– Be a hospital that ceased operations on or Be a hospital that ceased operations on or

after 11/29/89 orafter 11/29/89 or– A health clinic or health center that A health clinic or health center that

previously operated as a hospital before previously operated as a hospital before being downsized to a health clinic or health being downsized to a health clinic or health centercenter


– The facility must be located in a rural area of The facility must be located in a rural area of the state that has an established Medicare the state that has an established Medicare rural hospital flexibility program.rural hospital flexibility program.

– Facility must be located more than a 35 mile Facility must be located more than a 35 mile drive from any other hospital or CAH, or be drive from any other hospital or CAH, or be designated a “necessary provider” by the designated a “necessary provider” by the state (15 miles in mountainous terrain or state (15 miles in mountainous terrain or areas with only secondary roads).areas with only secondary roads).


– The facility must make available 24-hour The facility must make available 24-hour emergency care services.emergency care services.

– The facility must provide not more than 25 The facility must provide not more than 25 beds for acute (hospital level) inpatient care, beds for acute (hospital level) inpatient care, or in the case of a CAH with a swing bed or in the case of a CAH with a swing bed agreement, swing beds used for Skilled agreement, swing beds used for Skilled Nursing Facility (SNF) level of care.Nursing Facility (SNF) level of care.

– A CAH maintains a length of stay of no A CAH maintains a length of stay of no longer than 96 hours on average for Acute longer than 96 hours on average for Acute level of care patients.level of care patients.

CAH’s Exceed US Average in CAH’s Exceed US Average in Pt. SatisfactionPt. Satisfaction% of Pt. who reported that:% of Pt. who reported that: Mean Avg. Mean Avg. Mean Avg.Mean Avg.

CAH NationallyCAH Nationally All US All US HospitalsHospitals

Nurses always communicated wellNurses always communicated well 79%79% 74%74%

Doctors always communicated wellDoctors always communicated well 83%83% 80%80%

Pt. always received help as soon as wantedPt. always received help as soon as wanted 71%71% 62%62%

Pain was always controlledPain was always controlled 71%71% 68%68%

Staff always explained about medications before giving them to Staff always explained about medications before giving them to pt.pt.

63%63% 59%59%

Yes, staff gave pt. information about what to do during recovery Yes, staff gave pt. information about what to do during recovery at homeat home

82%82% 80%80%

Area around pt. room was always quiet at nightArea around pt. room was always quiet at night 61%61% 56%56%

Pt. room and bathroom were always cleanPt. room and bathroom were always clean 78%78% 69%69%

They gave an overall hospital rating of 9 or 10 on a 1-10 scaleThey gave an overall hospital rating of 9 or 10 on a 1-10 scale 70%70% 64%64%

Swing Bed UnitsSwing Bed Units

What are Swing Beds?What are Swing Beds?

• Transitional unit for individuals who Transitional unit for individuals who require skilled services for a short require skilled services for a short term following a hospital stay.term following a hospital stay.

• Typical LOS 2-3 weeksTypical LOS 2-3 weeks

Medicare Admission Medicare Admission GuidelinesGuidelines

• No guarantee of payment provision for No guarantee of payment provision for providers resulting in strict guidelines providers resulting in strict guidelines for admission including:for admission including:

– Determining if pt has met the 3 day Determining if pt has met the 3 day qualifying hospital stay and 30-day transfer qualifying hospital stay and 30-day transfer requirement.requirement.

Medicare Admission Medicare Admission Guidelines Cont…Guidelines Cont…

– Determine if pt. has Medicare Part A Determine if pt. has Medicare Part A benefits.benefits.• If no Part A Benefit, the responsibility of payment If no Part A Benefit, the responsibility of payment

must be explained to the pt. must be explained to the pt.

– Determine if pt. is appropriate medically for Determine if pt. is appropriate medically for admission to a Skilled Nursing Facility level admission to a Skilled Nursing Facility level of care.of care.

Skilled Nursing Facility Skilled Nursing Facility (SNF) Level of Services(SNF) Level of Services

Definition:Definition:• Skilled nursing and skilled rehabilitation Skilled nursing and skilled rehabilitation

services are those services furnished services are those services furnished based on the orders of a medical based on the orders of a medical professional that: professional that: – Require the skills of qualified technical or Require the skills of qualified technical or

professional health personnel such as professional health personnel such as registered nurses, licensed practical nurses, registered nurses, licensed practical nurses, physical therapists, occupational therapists, physical therapists, occupational therapists, and speech pathologists or audiologists.and speech pathologists or audiologists.


Definition Cont…Definition Cont…– Services must be provided directly by or Services must be provided directly by or

under the general supervision of these under the general supervision of these skilled nursing or skilled rehabilitation skilled nursing or skilled rehabilitation personnel to assure the safety of the patient personnel to assure the safety of the patient and to achieve the medically desired result.and to achieve the medically desired result.


Criteria for determining whether a Criteria for determining whether a service is skilled include:service is skilled include:

• If the complexity of a service prescribed is such If the complexity of a service prescribed is such that it can only be performed safely and/ or that it can only be performed safely and/ or effectively by or under the supervision of effectively by or under the supervision of skilled nursing or skilled rehabilitation skilled nursing or skilled rehabilitation personnel.personnel.

• The nature of the service and the skills The nature of the service and the skills required for a safe and effective delivery of required for a safe and effective delivery of that service. (The patient’s diagnosis or that service. (The patient’s diagnosis or prognosis should never be the sole prognosis should never be the sole determinant of whether a service is skilled.)determinant of whether a service is skilled.)



• When rehabilitative services are the primary When rehabilitative services are the primary services it is key whether or not the skills of a services it is key whether or not the skills of a therapist are needed. (Can the services be therapist are needed. (Can the services be carried out in an outpatient setting or by the carried out in an outpatient setting or by the assistance of non-skilled personnel?)assistance of non-skilled personnel?)



• A service that is ordinarily not considered A service that is ordinarily not considered skilled may be considered so in cases where, skilled may be considered so in cases where, because of special medical complications because of special medical complications skilled nursing or skilled rehabilitation skilled nursing or skilled rehabilitation personnel are required to perform or supervise personnel are required to perform or supervise the service or observe the patient. These the service or observe the patient. These complications must be documented in the complications must be documented in the physician’s orders as well as the therapy and/ physician’s orders as well as the therapy and/ or nursing notes. or nursing notes.



• To determine whether services provided to To determine whether services provided to Swing-Bed patients are skilled, you must Swing-Bed patients are skilled, you must considered whether individual services are considered whether individual services are skilled or in light of the patient’s total condition skilled or in light of the patient’s total condition skilled management of unskilled services are skilled management of unskilled services are necessary. (The importance of a particular necessary. (The importance of a particular service to a patient or the frequency with service to a patient or the frequency with which it must be performed, does not, by itself, which it must be performed, does not, by itself, make a service skilled.)make a service skilled.)



• The possibility of adverse effects from the The possibility of adverse effects from the improper performance of an otherwise improper performance of an otherwise unskilled service does not make it a skilled unskilled service does not make it a skilled service unless there is documentation to service unless there is documentation to support the need for skilled nursing or skilled support the need for skilled nursing or skilled rehabilitation personnel.rehabilitation personnel.

• Teaching and training activities that require Teaching and training activities that require skilled personnel to teach a patient how to skilled personnel to teach a patient how to manage his treatment regimen would manage his treatment regimen would constitute skilled services.constitute skilled services.

Case ExamplesCase Examples


• A 70yr old female presents to the ER A 70yr old female presents to the ER with mental status changes, following with mental status changes, following tests she is admitted to acute care to be tests she is admitted to acute care to be treated for a UTI. After three days of treated for a UTI. After three days of antibiotics, minimal improvement is antibiotics, minimal improvement is seen. She is then admitted to swing bed seen. She is then admitted to swing bed to receive a 10 day antibiotic circuit.to receive a 10 day antibiotic circuit.


• An 82yr old male who resides at home An 82yr old male who resides at home with the assistance of only his elderly with the assistance of only his elderly and disabled wife. After years of and disabled wife. After years of suffering with knee pain due to arthritis suffering with knee pain due to arthritis he receives a total right knee he receives a total right knee replacement. Following surgery and a replacement. Following surgery and a brief recovery he is transferred to swing brief recovery he is transferred to swing bed to receive physical therapy for bed to receive physical therapy for mobility and ambulation to better equip mobility and ambulation to better equip him to go home following discharge.him to go home following discharge.


• A 67yr old female was treated for a CVA. A 67yr old female was treated for a CVA. She is declared medically stable but still She is declared medically stable but still struggles with swallowing and speaking. struggles with swallowing and speaking. She is transferred to a swing bed unit to She is transferred to a swing bed unit to receive speech therapy.receive speech therapy.

Payment/ CoveragePayment/ Coverage

Medicare Coverage- Part AMedicare Coverage- Part A

• Medicare Part A covers skilled services Medicare Part A covers skilled services for beneficiaries requiring additional for beneficiaries requiring additional skilled nursing care and/ or skilled nursing care and/ or rehabilitation services following rehabilitation services following hospitalization for up to 100 days per hospitalization for up to 100 days per course of illness. course of illness. – Beneficiaries pay nothing for the first 20 Beneficiaries pay nothing for the first 20

days and a daily co-payment of $141.53 days and a daily co-payment of $141.53 (2011) for days 21-100(2011) for days 21-100

– This co-payment may be covered by another This co-payment may be covered by another insuranceinsurance

Increased Post-Acute Access for Increased Post-Acute Access for Medicare BeneficiariesMedicare Beneficiaries

• Improved Quality of CareImproved Quality of Care• Rural hospitals and CAHs that have Rural hospitals and CAHs that have

swing bed approval increase Medicare swing bed approval increase Medicare beneficiary access to post-acute SNF beneficiary access to post-acute SNF care and maximize the efficiency of care and maximize the efficiency of operations by meeting unpredictable operations by meeting unpredictable demands for acute and LTC.demands for acute and LTC.

Increased Post-Acute Access for Increased Post-Acute Access for Medicare BeneficiariesMedicare Beneficiaries

• In rural areas where access to In rural areas where access to services may be limited, patients services may be limited, patients ready for acute discharge from a ready for acute discharge from a facility may need more care and facility may need more care and support than can be achieved support than can be achieved through a discharge to home with through a discharge to home with home health services.home health services.

Benefit to Rural Geriatric Benefit to Rural Geriatric CommunityCommunity

Proximity of CareProximity of Care

• Large Percentage of WV Elderly Large Percentage of WV Elderly Reside in Rural AreasReside in Rural Areas– Rural elderly can receive transitional Rural elderly can receive transitional

skilled services in a facility closer to skilled services in a facility closer to home.home.• Easier for support network to be actively Easier for support network to be actively

involved in pt. care and discharge involved in pt. care and discharge planning.planning.

Transitional EaseTransitional Ease

• Psychologically and emotionally, Psychologically and emotionally, swing bed admissions may be less swing bed admissions may be less traumatic and threatening for the traumatic and threatening for the patient. Admission to a swing bed patient. Admission to a swing bed feels more like a continued hospital feels more like a continued hospital stay to the patient and helps stay to the patient and helps improve continued recovery and a improve continued recovery and a return to independence.return to independence.

Community Centered CareCommunity Centered Care

• EmploymentEmployment– CAHs are major employers in rural CAHs are major employers in rural

areas for which they are present.areas for which they are present.– Provides an opportunity for Provides an opportunity for

professionals from rural communities professionals from rural communities to remain and utilize their skills in the to remain and utilize their skills in the communities from which they communities from which they originated.originated.

Community Centered CareCommunity Centered Care

• Community Participation and Community Participation and SupportSupport– CAHs sponsor community activities CAHs sponsor community activities

based on wellnessbased on wellness• Health FairsHealth Fairs• Blood/ Health ScreeningsBlood/ Health Screenings• Advance DirectivesAdvance Directives• EducationEducation

Critical Access Hospitals of Critical Access Hospitals of WVWV

• Boone Memorial Boone Memorial HospitalHospital

• Braxton County Braxton County Memorial HospitalMemorial Hospital

• Broaddus HospitalBroaddus Hospital• Grafton City HospitalGrafton City Hospital• Grant Memorial Grant Memorial

HospitalHospital• Hampshire Memorial Hampshire Memorial

HospitalHospital

• Jefferson Memorial Jefferson Memorial HospitalHospital

• Minnie Hamilton Minnie Hamilton Healthcare CenterHealthcare Center

• Montgomery General Montgomery General HospitalHospital

• Morgan County War Morgan County War Memorial HospitalMemorial Hospital

• Plateau Medical Plateau Medical CenterCenter

Critical Access Hospitals of Critical Access Hospitals of WVWV

• Pocahontas Memorial Pocahontas Memorial HospitalHospital

• Potomac Valley Potomac Valley HospitalHospital

• Preston Memorial Preston Memorial Hospital CorporationHospital Corporation

• Roane General Roane General HospitalHospital

• Sistersville General Sistersville General HospitalHospital

• Summers County Summers County Appalachian Regional Appalachian Regional HospitalHospital

• Webster County Webster County Memorial HospitalMemorial Hospital

Questions?Questions?

ReferencesReferences

Casey, M., Burlew, M., Moscovice, I., & University of Casey, M., Burlew, M., Moscovice, I., & University of Minnesota Rural Health Research Center. (2010). Minnesota Rural Health Research Center. (2010). Critical Critical access hospital year 5 hospital compare access hospital year 5 hospital compare participation participation and quality measure results: Policy and quality measure results: Policy review #15. Flex review #15. Flex Monitoring Team: Federal Office of Monitoring Team: Federal Office of Rural Health Policy.Rural Health Policy.

Centers for Medicare and Medicaid Services. (2008). Centers for Medicare and Medicaid Services. (2008). Fact Fact sheet: Critical access hospital. American sheet: Critical access hospital. American Medical Medical Association.Association.

Centers for Medicare and Medicaid Services. (2010). Centers for Medicare and Medicaid Services. (2010). Critical Critical access hospital: Part A. Trailblazer Health access hospital: Part A. Trailblazer Health Enterprises, Enterprises, LLC. LLC.


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National Rural Health Association, 22National Rural Health Association, 22(2), 140-146.(2), 140-146.

Department of Health and Human Resources Centers forDepartment of Health and Human Resources Centers forMedicare and Medicaid Services. (2010). Swing bed: Medicare and Medicaid Services. (2010). Swing bed: Rural health Rural health fact sheet series. Medicare Learning fact sheet series. Medicare Learning Network.Network.

Division of Rural Health, West Virginia Department of Division of Rural Health, West Virginia Department of Health Health and Human Resources. West Virginia rural and Human Resources. West Virginia rural hospital hospital

flexibility (flex) program. Retrieved from flexibility (flex) program. Retrieved from http://www.wvochs.org/orhp/rhfp.aspx


Gale, J.A., Lenardson, J., Race, M., Gregg, W.R., Casey, Gale, J.A., Lenardson, J., Race, M., Gregg, W.R., Casey, M., M., Richardson, I., & Rutledge, S. (2007). State IRichardson, I., & Rutledge, S. (2007). State I nitiatives nitiatives funded by the medicare rural hospital funded by the medicare rural hospital flexibility grant flexibility grant program: Policy review #3. Flex program: Policy review #3. Flex Monitoring Team: Monitoring Team: Federal Office of Rural Health Federal Office of Rural Health Policy.Policy.

Herbert, D. & Davis-Fleming, J. (2009). Boost your Herbert, D. & Davis-Fleming, J. (2009). Boost your critical critical access hospital bottom line with swing bed access hospital bottom line with swing bed designation. designation. Washington Healthcare News, 4Washington Healthcare News, 4(3), 1-3.(3), 1-3.

ReferencesReferences Lutfiyya, M.N., Bhat, D.K., Gandhi, S.R., Nguyen, C., Lutfiyya, M.N., Bhat, D.K., Gandhi, S.R., Nguyen, C.,

Weidenbacher-Hoper, V. & Lipsky, M. (2007). A Weidenbacher-Hoper, V. & Lipsky, M. (2007). A comparison of quality of care indicators in urban comparison of quality of care indicators in urban acute care hospitals and rural critical access acute care hospitals and rural critical access hospitals in hospitals in the United States. the United States. International International Journal for Quality in Journal for Quality in Health Care, 19Health Care, 19(3), 141-149.(3), 141-149.

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Tai, W.C., Porell, F.W., & Adams, E.K. (2004). Hospital Tai, W.C., Porell, F.W., & Adams, E.K. (2004). Hospital choice of rural medicare beneficiaries: Patient, choice of rural medicare beneficiaries: Patient, hospital hospital attributes, and the patient-physician attributes, and the patient-physician relationship. relationship. HSR: HSR: Heal Services Research, 39Heal Services Research, 39(6), (6), 1903-1922.1903-1922.

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Critical Access Hospitals Quality Care in Rural West Virginia