Rural Health Networks Prove There Is Strength in Numbers

by Candi Helseth

Rural health networks have captured the attention of health care providers and policymakers as an important strategy for improving access to health care services for rural populations—and for their potential to improve health care quality.

Quality has dramatically improved in Michigan’s 36 Critical Access Hospitals (CAHs), which have voluntarily united under the umbrella of the Michigan Critical Access Hospital Quality Network (MICAH), formed in 2001. In Montana, it’s the same story. All 48 CAHs have voluntarily joined the Montana Rural Healthcare Performance Improvement Network (PIN), initially formed in 2002 with 14 CAHs. Saying they’re improving quality in small, rural hospitals is more than lip service; MICAH and PIN are among rural health networks in 49 states demonstrating measurable quality improvement (QI) results.

“Rural health networks are definitely documenting improved quality performance,” said Kristin Martinsen, Hospital State Division Director at the federal Office of Rural Health Policy. “Within the area of quality, networks can be a great tool for hospitals to improve outcomes. When these hospitals pool resources to network, those with fewer resources get access to resources they otherwise wouldn’t have. We’re not mandating networks in and of themselves, but networks can help achieve Flex program goals.”

Formed initially to support CAH participation in Flex QI programs, MICAH has branched out to address a variety of QI initiatives, measurements and projects specific to needs specified by CAH members. The Michigan Center for Rural Health (MCRH) and the Michigan Flex Program support MICAH, which is the only state-level nonprofit network solely devoted to CAH quality measurement and improvement issues, according to current President Ed Gamache.

As hospital CEO of Harbor Beach Community Hospital, Gamache personally sees the daily struggles unique to small CAH operations. Once predominantly a logging community on Michigan’s Lake Huron shoreline, Harbor Beach attracts thousands of tourists to its beaches. But only about 6,000 residents live in this area where the 15-bed hospital, with 39 long-term care beds, is more than 1.5 hours away from any of three major tertiary centers.

In Montana, 100 or more miles separate CAHs and seasonal weather conditions can make 10 miles impossible to travel. Staff grapples with limited resources, inadequate budgets and constant workforce turnovers, says PIN Flex Grant Director Carol Bischoff. There’s no time to research, implement and track quality improvement measures because nursing leadership is too busy doing hands-on patient care. PIN helps CAHs with quality improvement efforts and clinical and operational assistance.

Measuring Quality

Pediatric Care Staff

As a member of the Montana Rural Healthcare Performance Improvement Network, Livingston HealthCare is one of its CAHs that has involved pediatric care staff in focused education and hands-on procedure skills practice.

Both MICAH and PIN are ahead of the game in quality improvement, having already implemented QI studies and measures related to management of patients with pneumonia and heart care. The Flex Medicare Beneficiary Quality Improvement Project (MBQIP) rolled out in September by ORHP identifies management of pneumonia and heart care as priorities in MBQIP’s first phase. (See related story.)

The networks use quality measure tools to help define processes, outcomes, etc. From the initial collective endeavor to evaluate care provided for community-acquired pneumonia, MICAH’s measurement system now includes 26 quality metrics applicable to rural situations, according to Gamache. Michigan CAHs all have access to a web-based clinical benchmarking reporter.

“By working with all CAHs collectively, data becomes more relevant and performance levels are reflected more accurately as a whole,” Gamache elaborated. “As a result, MICAH can better identify how Michigan CAHs are performing and where improvement needs to be made. And these are rural facility relevant performance measures.”

With a goal of improving emergency care for pediatric patients statewide, PIN collaborated with MT Emergency Medical Services for Children (EMSC) to collect information about pediatric emergencies and document Emergency Department (ED) visits and care in 28 CAHs. Five PIN peer groups submitted baseline and remeasurement data for 422 pediatric cases over a year’s time. After identifying performance improvement goals, PIN involved CAH pediatric care staff in focused education and hands-on procedure skills practice. The study documented performance scales in areas such as patient assessment, medical care and trauma care. Every participating CAH recorded measurable improvements.

“We search for performance standards and national performance benchmarks when we build our studies,” said Kathy Wilcox, PIN Rural Hospital Quality Coordinator. “Our CAHs do a baseline data collection, a re-measurement after six months, and then we define opportunities for improvement. Those go back to the CAH so they see where their performance varied the most compared to national guidelines. They can see peer group and facility performance levels, which gives them two different groups for comparison.”

MICAH and PIN have several additional quality projects underway, and have shared information and collaborated on projects together. MICAH regularly publishes a Best Practices Model (No longer available online) on its projects. Network benchmarking gives CAHs solid information about what is working well in other states’ rural communities, Martinsen noted.

Offering Education and Recognition

Education and recognition are essential components for helping CAHs work independently and interdependently. Both networks communicate extensively via websites, telehealth webinars, conference calls, etc. They also sponsor regular face-to-face meetings and have established awards recognition programs. MICAH publishes CMS quality data for public access on the Michigan Health and Hospital Association website.

“Our CAHs are always looking to each other for education and information,” said Angela Emge, MICAH hospital programs manager. “We have a listserv that all of them use extensively. Following our quarterly quality meetings, I send out a newsletter that highlights discussions, decisions made, etc. There’s a lot of communication back and forth. They share documents and educate each other in addition to the education MICAH provides.”

Two Michigan CAHs used professional and public education to improve outcomes for stroke patients. A 2007 data review indicated that patient treatment times were too long from onset of symptoms and that thrombolytics were under-used. Family-specific education, distributed to 30,000 households, was designed to sharpen responses to stroke symptoms and ensure earlier hospital arrival. Professional education centered on thrombolytics education for medical staffs. From 2007 to 2009, average ER arrival time decreased from 327 minutes to 259 minutes. Thrombolytic administration increased from 1.8 percent for all ischemic stroke patients in 2007 to 6.5 percent in 2009.

Expanding Beyond State Lines

In addition to helping increase rural health care access, networks increase the effectiveness of network member institutions, and aid the diffusion of managed care in rural areas, according to Using Rural Health Networks to Address Local Needs: Five Case Studies (No longer available online). Network formations vary widely, some serving certain regions in a state, some statewide and some multi-state.

“I believe we are going to see more networks transcending state lines as they look to work together on joint initiatives and to share products/service lines,” said Sally Trnka, National Rural Health Resource Center Program Coordinator. “I firmly believe that networking is going to be vital to the success and viability of rural hospitals and CAHs. If you look at the way that the reform legislation is worded, we are headed towards a system that requires rural health care facilities to network together to better serve their patient populations.”


What Michigan and Montana have realized is that networks bring together rural providers to address health care problems that could not be solved by any single entity working alone. Gamache said MICAH’s quality network has provided a framework that helps CAHs develop data useful to their performance and the ability to share their successes. Through the use of MICAH developed measures, CAHs can participate now in the Michigan Blue Cross Blue Shield (BCBS) pay for performance program, Gamache said, noting that the program “was historically developed for larger facilities.”

“PIN strengthens the fragile infrastructure of our state’s small rural CAHs,” Bischoff asserted. “We went from these hospitals not knowing anyone in other facilities to literally giving the shirts off their backs to their peers, sharing a tremendous amount of knowledge. And in the process, they also save a tremendous amount of time.”

Back to: Fall 2011 Issue