The Flex Program has two goals
- To provide training and support to Critical Access Hospitals (CAH) as they seek to improve services.
- To support hospitals seeking a CAH designation.
Critical Access Hospital (CAH) Designation Requirements
- The standard location of a CAH is more than a 35-mile drive on primary roads (or, in the case of mountainous terrain or areas with only secondary roads available, a 15-mile drive) from another hospital.
- CAHs maintain no more than 25 inpatient beds, which may be used for either inpatient or swing-bed services.
- CAHs provide acute inpatient care for a period that does not exceed 96 hours per patient on an annual average.
- Additional information regarding CAH designation can be found in the Code of Federal Regulations (CFR), and Wyoming license information and application can be found Here.
Submission Deadlines – Click Here
- Starting in the calendar year 2025, hospitals will collect data to report on the updated MBQIP core measure set as part of the Flex Program.
- The MBQIP Measures Continuing from Prior Years and the Measures Being Added can be found Here
Due January 2, 2025
- Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Q2 2024 encounters (7-1-24 to 9-30-24)
Due January 31, 2025 – EDTC
- If you have any questions please reach out to Rochelle Spinarski or Gail Van Buren
- Resources can be found here!
Due February 3, 2025: Median Time from ED arrival to ED departure (OP18)
- Median Time from ED arrival to ED departure (OP18) for Q3 2004 encounters (7-1-24 to 9-30-24).
Due February 28, 2025 – Safe Use of Opioids, Concurrent Prescribing
- Q3 and Q4 encounters (7-1-24 to 12-31-24). Submission is through the HQR Secure Porta
What’s the difference between the Overall Hospital Quality Star Rating and the HCAHPS Star Rating Program?
Overall Star Rating
Overall Hospital Quality Star Rating
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- The Overall Hospital Quality Star Rating (Overall Star Rating) summarizes a variety of measures across 5 areas of quality into a single star rating for each hospital. Once reporting thresholds are met, a hospital’s Overall Star Rating is calculated using only those measures for which data are available. Hospitals report data to the Centers for Medicare & Medicaid Services (CMS) through the Hospital Inpatient Quality Reporting (IQR) Program, Hospital Outpatient Quality Reporting (OQR) Program, Hospital Readmission Reduction Program (HRRP), Hospital-Acquired Condition (HAC) Reduction Program, and Hospital Value-Based Purchasing (VBP) Program. It can be difficult for low volume hospitals to meet and keep threshold requirements.
- CAHs are NOT required by the MBQIP program to participate in the Overall Hospital Quality Star Rating program. For an overview of Overall Hospital Quality Star Rating:
- Access Overview
HCAPS Star Rating
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- The Centers for Medicare & Medicaid Services (CMS) publishes HCAHPS Star Ratings to the Care Compare website. Eleven HCAHPS Star Ratings will appear on Care Compare: one for each of the 10 publicly reported HCAHPS measures, plus an HCAHPS Summary Star Rating. CMS updates the HCAHPS Star Ratings each quarter. All hospitals that participate in the HCAHPS Survey are eligible to receive HCAHPS Star Ratings; this includes both Inpatient Prospective Payment System (IPPS) hospitals and Critical Access Hospitals (CAH). IPPS hospitals are required to report HCAHPS as part of the Inpatient Quality Reporting program and CAHs voluntarily participate. Hospitals must have at least 100 completed surveys in a 12-month reporting period to be eligible for HCAHPS Star Ratings.
- CAHs are NOT required by the MBQIP program to participate in the HCAHPS Star Ratings Program.
- Program Assistance
QI RoundtablesSocial Drivers of Health 
- Recording Can be Found Here
- Passcode: %CiSU5%h
Past Roundtable: Health Equity
- This meeting focused on reporting, hospitals’ responses to the health equity survey questions, and the next steps.
- Recording Can Be Found Here
- Passcode: q86nvs@i
CMS Abstraction and Reporting Tool
CMS announced that the CMS Abstraction and Reporting Tool (CART)-Outpatient 1.25.0 has been released and is available on the QualityNet website, http://www.qualitynet.org.
This release contains updates to CART Outpatient 1.25.0 to support the Sex Data Element changes as listed in Specifications Manual 17.0a. This CART version must be used for encounter dates 07-01-24 through 09-30-24.
- Details of the new Sex Data Elements are listed below:
- Sex Assigned at Birth – Required
- Sexual Orientation – Voluntary
- Gender Identity – Voluntary
NOTES FROM OUR RQITA SUPPORT TEAM – Found here
Joint Commissions National Patient Safety Goals
Effective January 1, 2025
Included below are links to the 2025 National Patient Safety Goals for the Critical Access Hospital Ptrogram
Financial & Operational Resources
Wyoming Financial Roundtables
Upcoming Roundtable – Wyoming CAH Success Stories
- December 18, 1:00 pm MST
- Register Here
Rural Emergency Hospital (REH) Designation
Wyoming Healthcare Licensing and Surveys will add the REH designation through a change in Rules, but this has not occurred as of September 2024.
The Rural Emergency Hospital (REH) is a new Medicare provider type created to address the growing concern over rural hospital closures. The Rural Emergency Hospital (REH) Technical Assistance Center offers education concerning the new REH designation, including eligibility (does an organization meet the REH requirements), assessment (assess the benefits and downsides of conversion, including financial and operational analysis), assistance with the application process, assistance with implementing operational and staffing changes, and post-conversion support.
REH Resources
Ken Harmon (kh@rhrco.org) is the technical assistance coordinator for Wyoming.
Flex Scholarship Program
Open
Who can apply?
- Wyoming Flex Program scholarship funds are available to support anyone working at a Wyoming Critical Access Hospital that reports Medicare Beneficiary Quality Improvement Project (MBQIP) Measures.
- Flex scholarships are also available for all rural Wyoming Emergency Medical Services (EMS) personnel—they do not have to be attached to a CAH.
- Funds are reimbursed to the CAH or independent EMS personnel upon receipt of all documentation. The full process can be found here.
- For information on scholarships or MBQIP please contact the Flex Program Manager.
What can scholarships be used for?
Training scholarships must advance one of the Flex program goals: quality, finances, operations, population health, or EMS improvement.
Approval Process
All scholarships need to be submitted by the organization’s point of contact. The funds will be approved based on availability and how closely they fit the Flex Program goals. Scholarships cannot be used for hands-on training with patients.
Application Link
This project is/was supported by the Health Resources and Service Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U2WRH33330-01-00 Medicare Rural Hospital Flexibility (Flex) Program and 0% financed with nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements to be inferred by HRSA, HHS, or the U.S. Government.