Rural Community Infrastructure Roundtable Meeting August 28, 2018 Kristi Martinsen Hospital State Division Director, Federal Office of Rural Health Policy Health Resources and Services Administration (HRSA)

Health Resources and Services Administration (HRSA) Overview Supports more than 90 programs that provide health care to people who are geographically isolated, economically or medically challenged HRSA does this through grants and cooperative agreements to more than 3,000 awardees, including community and faith- based organizations, colleges and universities, hospitals, state, local, and tribal governments, and private entities Every year, HRSA programs serve tens of millions of people, including people living with HIV/AIDS, pregnant women, mothers and their families, and those otherwise unable to access quality health care

HRSA’s Regions

Office of Regional Operations HRSA’s national network of 10 Regional Offices strive to increase access to quality care, information and resources. Provide responsive outreach and assistance to HRSA grantees, target populations and stakeholders Partner with and convene local and regional stakeholders to advance HRSA priorities Extend the reach of HRSA’s Bureau and Office programs Represent HRSA at meetings and events to promote HHS/HRSA initiatives Identify emerging regional/state trends, priorities, and effective strategies Office of Regional Operations

FORHP Programs and Activities Community-Based Division Hospital-State Division Pilot Programs for Rural Communities Expanding the Community Health Gateway Public Health Programs Black Lung and Radiation Exposure Grants Focusing on Performance and Quality Improvement for Small Rural Hospitals State Offices of Rural Health Office for the Advancement of Telehealth Policy Research Division Policy and Regulatory Analysis Research Telehealth Network Grants Telehealth Resource Centers Licensure and Portability As you think about emerging issues, a lot of what we’re dealing with is realizing that we have to help RH providers make the changes they need to in the Val to Vol transition Need to get more value out of the care that is provided; to get better outcomes and to get control of costs Bulk of the focus on this transition has been at urban level federally; as states you have the opportunity to help rural hospitals and clinics make that transition. CBD: Non categorical p-gs; may be way to fund the initial steps of some of the ideas that emerge out of this work. Similarly, the work in HSD $ to help CAHs and SRHs focus on Q and PI. And it may be that TH is one of the things you all identify as a way to move forward. We have programs for TA and direct funding that may be of help. FY 2018: Addition of Rural Communities Opioid Response Program

Rural Safety Net Providers: Rural Hospitals Critical Access Hospitals (CAHs) – This is a special designation under Medicare for facilities have fewer than 25 beds and a limitation on length of stay of an average of 96 hours. Medicare Dependent Hospitals (MDHs) – This is a special designation under Medicare for small rural hospitals where Medicare patients comprise at least 60 percent of their patient base. They have the option of receiving a special payment rate under Medicare based on historic costs. Sole Community Hospitals (SCHs) – This is a special designation under Medicare for small rural hospitals that are 35 miles from another acute-care hospital. They also receive the option of a special payment rate under Medicare in recognition of their geographic isolation and the challenge of serving that population. Rural Prospective Payment System Hospitals (PPS) – These are regular general acute care hospitals reimbursement by Medicare on the standard pre-determined, fixed amount for services. CAHs are paid by Medicare on a cost basis for in- and outpatient services. Within the 25-bed limit, the beds can be used for both acute services and skilled nursing services through what are called Swing Beds, meaning they can switch from acute to skilled care and staffed based on those changes. Non-profit CAHs may also qualify for the 340B discount drug program.

Rural Safety Net Providers: RHCs and FQHCs Rural Health Clinics (RHCs) – These are Medicare-certified clinics that were created by The Rural Health Clinic Services Act (RHC Act) of 1977 and receive certification, based in part on their location, from the Centers for Medicare & Medicaid Services (CMS) for participation in the Medicare and Medicaid programs. The Health Center Program (also known as Federally Qualified Health Centers): This program is administered by HRSA’s Bureau of Primary Health Care and was established in the 1960s as a War on Poverty demonstration program. The aim of the program was to provide access points to health and social services for medically underserved and disenfranchised populations in urban and rural areas.

State Offices of Rural Health Share information, resources and innovative projects with other rural health stakeholders Coordinate with other state partners on rural health issues Link rural health stakeholders to Federal and state resources Rural recruitment and retention Connect with your SORH: https://nosorh.org/nosorh-members/

Telehealth Resource Centers (TRCs) OAT also provides support through the Telehealth Resource Center Grant Program. TRCs provide assistance, education, and information on telehealth to expand delivery of health care to rural and underserved populations. There are 12 Regional TRCs and two National TRCs, one focusing on policy and the other on technology. Assistance is generally free of charge (up to 10 hours of free technical consulting). Types of assistance include: How To Get Started/Strategic Planning Program/Protocol Development Business Model Development/Reimbursement Program Evaluation/Quality Assessment Best Practices/Networking Guidance on selecting appropriate technology Guidance on legal, regulatory and other policy issues

Resources and Tools Regarding Capital Needs These are the areas where FORHP has done the most relevant work in terms of what will be of interest to potential capital providers for rural health care. The research has been more focused on providing tools to prepare hospitals for identifying funding sources and planning for their use.

Are you ready to begin a capital project? Toolkit 2/23/2019 Tools & Resources National Rural Health Resource Center, with Capital Link Are you ready to begin a capital project? Toolkit Related Webinars Strategic Capital Planning and Capital Budgeting Operational Considerations for Facility Planning and Capital Project Management Laying the Groundwork for a Capital Campaign Business Planning and Financial Projections for Capital Projects Rural Health Information Hub - Financing Capital for Rural The Rural Health Information Hub - provides online access to current resources and tools to help you learn about rural health needs and work to address them. Below are a few of those resources FORHP has funded and that can be used when working w/rural health care facilities and funders to better understand the nuances of working in rural communities: Financing Capital Investments in Rural Health Care: A Resource Overview -this document helps hospital administrators, board members, rural administrators, state associations, community lenders, and community leaders better understand and identify federally sponsored healthcare financing options. Use: Many of the programs noted are through USDA and what’s outlined in this resource are the qualifications and how health care systems can best access and utilize those resources. There are also programs from Treasury and the Small Business Administration that can be leveraged for the benefit of healthcare systems. Are You Ready to Begin a Capital Project? -This document is to provide both a guide and useful tools to evaluate organizational readiness to begin the capital project development process, with the goal of helping them avoid the pitfalls that insufficiently planned projects can encounter. Use: As a toolkit, this is a good technical assistance piece that lets a funder provide pre-planning support to healthcare organizations and help create a snapshot of current status and readiness to take on a capital project. Rural Health Clinics and Critical Access Hospitals Capital Needs Assessment -In 2015, in conjunction with Capital Link, FORHP developed a capital needs assessment, to explore provider needs in more depth. Use: These findings can help target funding efforts and program development to ensure that capital is addressing current and project needs rather than health care systems trying to adapt projects to fit available capital.

2/23/2019 Tools & Resources Delta Region Community Health Systems Development Program https://www.ruralcenter.org/drchsd Vulnerable Hospitals Toolkit (2016) https://nosorh.org/wp- content/uploads/2016/11/Vulnerable-Hospital- Toolkit-Excerpt.pdf Critical Access Hospital Replacement Process: Blueprint and Roadmap (2010 –oldies but goodies) https://www.ruralcenter.org/sites/default/files/cahrepl acementprocess_0.doc

Rural Health Information Hub (RHIhub) Capital Funding Capital Funding for Rural Healthcare major federal grant or loan programs that support capital projects for rural healthcare facilities? foundations support capital projects for rural healthcare facilities low-interest loans available to rural facilities other funding available to finance capital projects Provides customized assistance By phone: 1.800.270.1898 By email: info@ruralhealthinfo.org https://www.ruralhealthinfo.org/ Funded by HRSA’s Federal Office of Rural Health Policy. The RHIhub can help you: Plan—find toolkits and program models that show what works in rural communities so that you can build effective community health programs. Locate statistics, maps, and more to help you demonstrate need in your area. Develop—get the information you need to build, maintain, and improve services in your community. The RHIhub online library offers access to thousands of resources from organizations across the U.S. Learn—gain insight and understanding of the issues affecting rural America through topic guides, timely news, and updates. Every morning you can get the latest news and regulations relevant to rural health. Hear right away about the newest key reports and opportunities from federal agencies and national organizations via the website, social media, or our regular email updates. Connect—find others who have passion and expertise in rural health issues. The hub’s resources can help you identify organizations and experts on a variety of topics, as well as in your state. Source: https://www.hrsa.gov/ruralhealth/resources/

Capital Link (www.caplink.org)

Kristi Martinsen Hospital State Division Director Federal Office of Rural Health Policy HRSA 301-594-4438 kmartinsen@hrsa.gov

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