Bingham Memorial Hospital is a 25 bed Critical Access Hospital (CAH) that conver
ID: 210172 • Letter: B
Question
Bingham Memorial Hospital is a 25 bed Critical Access Hospital (CAH) that converted to CAH status January 1, 2004, making it the 24th hospital to convert in Idaho and the 836th to covert in the U.S. The hospital offers intensive care and critical care, emergency care, general surgery, and many specialties as listed below. The hospital also offers a variety of outpatient services including physical therapy, speech language pathology, sports medicine, occupational therapy, respiratory therapy, laboratory, education, and nutrition services. Bingham Memorial Hospital is unusual as a CAH in terms of the array of services it provides and its financial stability. It is a thriving, rural community hospital that not only improves access to quality health care services for underserved populations but also contributes significantly to the economic well-being of its community. Bingham Memorial Hospital was selected for a program evaluation to examine program effectiveness and impact on it has had on local communities. Following are excerpts and findings from the evaluation report: In 2007 the hospital converted from county owned to 501(c)3 not-for profit status. This has allowed the system greater flexibility in its operations and planning but also placed a yearly financial requirement to compensate Bingham County, which maintains ownership of the facility, up to $450,000 per year for rent and other considerations. • BMH went from 90 employees and $9 million budget to 620 employees and over $80 million budget in a little over a decade. • The CAH payment methodology gives the hospital an opportunity to provide more and better care and still remain financially viable. • The scope of services provided at BMH has increased dramatically and BMH has become a destination hospital for some specialties such as neurosurgery and bariatric surgery, as indicated by the broad distribution of patient origin zip codes. • CAH status has enabled the facility to operate as a hospital that supports itself. It brought services not typical for CAHs, including spine surgery and other orthopedic programs, and helped bring patients from outside of the community. • BMH has worked hard to provide high quality service and improve both patient and physician experiences. For example BMH allows patient visits at any time and works to make sure that patients’ expectations are met. • By successfully attracting patients from other communities due to BMH’s access, level of quality, and range of services, as indicated by a patient origin zip code analysis of elective surgeries in 2011 and by patient satisfaction measures, great improvements have been made to the hospital’s previously poor local reputation of 15-plus years ago. This has helped the local community change its perception of care as “care improved” at BMH. • BMH has partnered with physicians very well. Physicians are involved in structure, governance, and decision making. All BMH employed physicians have agreed to work with students, and BMH has received an FDA research license. BMH offers continuing medical education (CME) and public community seminars on topics such as lap banding, pain management, and orthopedic joint replacement in order to educate both the public and the physician community, and has received CME certification. • Converting to 501(c)3 status has added complexity to paperwork and reporting. • Community health education and behavioral health promotion remain real problems and require much more attention. • The distribution of care in the Emergency Department is approximately 25% emergency, 45% urgent, and 30% primary care. Many patients who are either uninsured or under-insured come to the ED for non-emergent care, which is more expensive when received in the ED. The end results are higher volumes in the ED, a financial burden on the hospital due to a higher proportion of uncompensated care, and problems with continuity and comprehensiveness of care. • The Health IT installation (Electronic Health Record, EHR) is promising and still under implementation. It has been challenging and frustrating for many staff members and some physicians. But this is improving as the system is learned and tailored to the environment at BMH Although BMH is located between areas served by larger regional facilities, access to primary care in the region has been greatly improved by the expanded services BMH provides, as measured by increased patient care volume and increased numbers of primary care providers and services such as urgent care practices. This includes inpatient and ambulatory care for both local and regional patients, especially those patients eligible for Medicare, Medicaid, and SCHIP. According to study participants, access has also been improved for residents of the Fort Hall Shoshone-Bannock Reservation located less than 13 miles from Blackfoot. • Hospital staff report that CAH status has helped advance patient safety and overall quality of care. For example, the Joint Commission’s Accreditation Quality Report for 2011 reported that Bingham Memorial Hospital met National Patient Safety Goals for 2011. • Both patients and staff report their overall opinion of the care provided at the hospital as not only greatly improving since achieving Critical Access Hospital status but also as having become the driving force for all hospital goals and objectives. • An electronic health record (EHR) system at BMH went live in January 2012. HIT improvement through the implementation of an EHR has been a major goal for BMH, and the hospital expects to meet national Meaningful Use requirements. • Availability of EHR data has increased the ability of the hospital system to monitor and improve provider (especially physician) involvement in quality improvement and changes in patient care outcomes. • The hospital system and all hospital departments have specific sets of quality indicators that are tracked and reported through a number of quality monitoring systems. • All case study participants report a need for additional community education regarding health quality, safety, and healthy living. • Coordination and continuity of care can be a challenge as such a high proportion of patients are uninsured or underinsured. • The Skilled Nursing Facility continues to experience a high turnover rate in personnel. • The recent EHR installation has been challenging in some departments and will require time to reach its full potential in monitoring quality improvement. Having read the above description CAREFULLY, please provide a detailed summary of the process and outcome objectives evaluated in this program. Be clear as to WHY you feel that your selections are EITHER process or outcome objectives. If useful, provide any data or findings that support your conclusions. In addition, if you were to improve this program moving forward, what are the various elements you would examine in a SWOT analysis? Be clear as to which aspects would correspond to each "letter" of the SWOT acronym, including why you think they belong there.
Explanation / Answer
Critical Access Hospital is a designation given to eligible rural hospitals, or those grandfathered as rural, by the Centers for Medicare and Medicaid Services (CMS). Congress created the Critical Access Hospital (CAH) designation through the Balanced Budget Act of 1997 (Public Law 105-33) in response to a string of rural hospital closures during the 1980s and early 1990s. Since its creation, Congress has amended the CAH designation and related program requirements several times through additional legislation.
The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. To accomplish this goal, CAHs receive certain benefits, such as cost-based reimbursement for Medicare services. (see What are the benefits of CAH status?)
Eligible hospitals must meet the following conditions to obtain CAH designation:
Also authorized in the Balanced Budget Act of 1997, Congress created the Medicare Rural Hospital Flexibility Program (Flex Program) to support new and existing CAHs.
This guide provides resources concerning the following CAH-related areas:
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