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Critical access hospitals: Meeting underserved community needs

Gaston, Sharon, Moutoux, MPH, BSN, RN, CIC; Walker, Barbara, Wyand, BSN, RN, CIC

doi: 10.1097/01.NURSE.0000531889.16311.c9
Feature: New Horizons

Critical access facilities—hospitals of 25 or fewer beds—were created to meet the needs of medically underserved communities. This article details their scope and function and discusses new professional opportunities these venues offer nurses.

Sharon Moutoux Gaston is the assistant CEO, infection control director, and risk manager at Braxton County Memorial Hospital in Gassaway, W.V. Barbara Wyand Walker is an infection control coordinator at Greenbrier Valley Medical Center in Ronceverte, W.V.

The authors have disclosed no financial relationships related to this article.



OF THE OVER 5,000 hospitals in the United States, 1,343 of them are designated critical access hospitals (CAHs).1 CAH facilities are small hospitals of 25 or fewer beds.2 Congress created this special CAH designation under the Balanced Budget Act of 1997 to meet the needs of medically underserved communities.3 This article details the role of CAHs in today's healthcare system and explores some differences and similarities for nurses working in this venue compared with non-CAHs. It also demonstrates the importance of interdepartmental cooperation by providing an example of the role of the infection preventionist in the rural West Virginia CAH program.

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CAHs: A closer look

The CAH program began in 1997 under the Medicare Rural Hospital Flexibility Program, known commonly as the Flex Program. It established reimbursement types for smaller hospitals meeting criteria outlined in the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation 42CFR485.2,4,5 (See Flex program criteria.)

Within this structure, CAHs may vary in services offered. All must maintain emergency and general medical services. Many have outpatient services, home health, rehabilitation, hospice, and long-term-care departments. ICUs, as well as surgery and obstetric services, are optional. Surgery may be general or specialized depending on community needs and specialist availability; most surgeries are outpatient. Lab and diagnostic imaging services are available, although many CAHs outsource all or part of these; for example, they may utilize a reference lab for microbiology and a mobile magnetic resonance imaging (MRI) vehicle once a week. Physicians and other qualified practitioners admitting to a CAH must certify that a patient may reasonably be expected to be discharged or transferred to another hospital within 96 hours after admission to the CAH.2 (Not all patients must be discharged at 96 hours, but the average patient stay at the end of the year must be 96 hours or less.)

On the surface, CAHs operate like any other small hospital, but with one major difference—the type of reimbursement for Medicare and Medicaid patients. Most Medicare-participating acute-care hospitals are reimbursed by the CMS based on diagnosis-related groupings (DRGs). CAHs are reimbursed on another system called cost-based reimbursement, which pays 101% of the reasonable costs to treat.2,3,6,10 This means that CMS pays what it costs the facility to care for the patient, rather than the DRG-based reimbursement of set fees for specific diagnoses. Because most CAHs have a high percentage of Medicare and Medicaid patients, the CAH designation can benefit the hospital financially.2,7

CAHs are also unique in several other ways, including staffing. Although state rules vary, federal requirements allow CAHs to close (and have no RN on site) if the facility is empty. Some states allow an LPN to cover a shift in place of an RN when nonacute patients (rehabilitation, swing bed, and hospice patients) are present. A CAH is required to have at least one physician, but he or she isn't required to be continually on site. Midlevel practitioners such as PAs and NPs can function independently and provide direct service, such as emergency care, as long as a physician is available by phone, direct radio, or other electronic means for consultation, assistance, or referral.5,6 To help with medical staff recruitment, physicians and certain other specialists (for example, CRNAs, psychiatrists, and podiatrists) may qualify for incentive bonuses to practice in CAHs.2

Smaller case volumes and shortages of key services, as well as problems financing rural healthcare delivery, have frequently hampered the ability of rural healthcare providers to fully implement improvements and quality improvement programs. Even though a CAH in a rural community may be the only source of healthcare in a wide geographic area, rural communities historically have been at the margins of healthcare, with much of the attention and quality initiatives developed for urban healthcare facilities.8 As a result, mainstream healthcare recommendations don't always apply to rural healthcare settings. For example, inpatient care in rural hospitals is often a smaller part of the services offered than in urban hospitals, and specialized services are beyond the scope of many. Patient transfers to larger facilities are frequently necessary when care beyond the CAH's scope is required.8 At Braxton County Memorial Hospital (BCMH) in West Virginia, for periodic quality improvement purposes patient transfers are audited for appropriateness under an agreement with one of the tertiary hospitals.

Despite the smaller number of patients, nursing is demanding for the CAH nurse, who must function as a generalist and be competent in two or more specialty clinical areas. As an example, medical-surgical and ED nurses must be competent in caring for both adult and pediatric patients and may move between several units in one work shift.7,9

The rural practice environment itself has features that affect practice differently than in the urban environment. Factors inherent in the rural population include large numbers of uninsured patients; more poverty; higher rates of risky behaviors such as cigarette smoking and excessive alcohol intake; and more obesity. In addition, CAH nurses often work with older equipment and spend more time teaching due to higher rates of patient illiteracy, including lack of healthcare knowledge. They also must deal with the ongoing challenge of maintaining patient confidentiality in a small community.9 CAHs also have fewer baccalaureate-prepared nurses and a lower ratio of RNs to unlicensed assistive personnel (UAP).9 In the authors' experience, other departments, such as pharmacy, lab, and radiology, have the same issues and may have only one professional on call at a time.

Despite low staffing, a CAH ED with capability to transfer to a tertiary care center must be ready to stabilize critical patients and prepare them for transfer; if this isn't possible due to distance or other issues such as weather and poor roads, the CAH must admit and treat critically ill patients.7 Meeting these challenges calls for preparation, dedication, and cooperation.

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Infection prevention at a West Virginia CAH

The first CAHs were established in Mississippi, Kansas, South Dakota, and West Virginia, and are now located in all states except Connecticut, Delaware, Maryland, New Jersey, and Rhode Island.1,10 Because the authors practice in West Virginia and are most familiar with the CAHs in this state, our example explores one of the West Virginia facilities.

West Virginia has 54 acute-care hospitals, of which 20 (37%) are CAH.10,11 BCMH is in the center of the state. Although Braxton county is large (510.81 square miles), it has only 14,500 residents, or 28 people per square mile.12 This county is considered 100% rural and lies in heavily forested mountainous terrain in the Allegheny Mountains.11 These mountains completely traverse the state from north to south, and although beautiful, often make travel difficult and access to healthcare problematic for many residents. According to the 2016 U.S. Census, 24% of the county's population falls below the poverty level, and 13% have no health coverage.11,12 To see how Braxton county compares with other U.S. counties, see

BCMH has 25 beds for adult medical-surgical and pediatric patients; it doesn't offer obstetric or ICU services. Average inpatient census on the medical-surgical unit is seven, which includes two acute patients, with observation and swing bed census of five. Over 70% of reimbursement is from Medicare and Medicaid.

The medical-surgical unit has a 1:6 nurse-to-patient ratio, depending on patient census and available RNs and UAP. There are always two clinicians on duty, although this may be one RN and one UAP. Census on this unit is usually three to five patients on average. In the ED, nurse staffing is staggered according to peak times and nurses are scheduled to start their 12-hour shifts at 0700, 1000, 1300, and 1900. If there are no ED patients, ED nurses may help on the inpatient unit, if needed. Nursing staff at BCMH are trained to provide whatever care the patients need without the support of specialized teams.

On average each month, 76 surgeries are performed, 880 emergency patients and 1,608 outpatients are seen, and 423 home health visits are made. The ED is open 24 hours a day with a physician on site and a hospitalist on call for the medical-surgical unit. Lab (including microbiology and blood bank), radiology (including computed tomography, nuclear medicine, and mammography), and cardiopulmonary services are available 7 days per week and surgery 3 days per week. An MRI traveling unit operates 2 days per week. Medical students and LPN students from West Virginia colleges have clinical rotations on site.

A good example of the multilayered approach in a CAH is the infection control preventionist (ICP). The ICP at BCMH is a BSN-prepared RN who's certified in infection control (CIC) and has a master's degree in public health administration. In this facility, she also carries out the jobs of assistant administrator, risk manager, and compliance officer. Overseeing all clinical and support services, including dietary, housekeeping, and medical records, fosters an integrative approach. She oversees multiple functions, including cleaning processes, food production, patient and family complaints, and the multiple medical record systems for documented or coded infections.

Besides administrative duties, this ICP supervises the infection control program and chairs the infection control committee. Some data collection and surveillance is delegated; for example, departments such as admitting, outpatient, home health, ED, and lab send her notices of probable or newly diagnosed infections, and the night-shift charge nurse compiles a report every midnight with the hospital census and number of indwelling urinary catheter days. The latter is used by the ICP for mandatory infection reporting data to aid in infection surveillance of susceptible patients and to document ongoing compliance with the critical access criteria required by CMS for maintaining CAH status.

All inpatient and outpatient culture results are reviewed by the ICP, and medical record reviews are done to ensure that patients are receiving the appropriate antibiotic. In this facility, the initial review is done by nursing staff in the ED and on the medical-surgical unit. These nurses document positive culture results in a log reviewed by the ICP, who refers any issues to the ED physician or hospitalist.

In addition to culture results and log reviews and as part of the antibiotic stewardship program, the ICP audits medical records for appropriate antibiotic usage patterns and assists with resistance reviews. She works closely with the lab supervisor and hospital pharmacy to assist in decisions regarding selection of formulary antibiotics based on these audit and review findings.

As in all hospitals, this CAH has various committees. The infection control committee is responsible for all infection control functions, including policies and procedures, patient or department reviews or investigations, infection rates, and antibiotic issues. In addition, all cleaning solutions and disinfectants are approved there.

Policies approved by the infection control committee are forwarded to a policy committee, which is a CAH requirement with mandated participation from administration, physician, nursing, midlevel practitioners, and a community member. An advantage of a small hospital is that key leaders may be readily available and new recommendations can be instituted quickly, allowing easier transitions to the next project. Larger hospitals typically have more committees and layers to pass before action can take place.

All hospitals receiving CMS monies must submit infection and quality data to CMS through the CDC's National Healthcare Surveillance Network infection reporting program and the Medicare Beneficiary Quality Improvement Project; however, these requirements aren't as comprehensive as at larger acute-care facilities; at BCMH, the only required report is for catheter-associated urinary tract infections, although others can be reported if desired. CAHs must also undergo accreditation surveys; CMS-approved agencies such as The Joint Commission are available as an option, although CAH facilities may prefer to be surveyed by an in-state health department agency (such as the Office of Health Facility Licensure and Certification), which is what BCMH elects.13 With the joint roles of administration, risk, and infection control, the ICP at BCMH is intensely involved in all aspects of all surveys for the entire period.

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Serving the community

CAHs benefit patients and the rural community by providing local access to high-quality healthcare, as well as providing jobs within the community and tax revenue to the county. Communication, cooperation, and interdependence between providers, disciplines, and other hospitals are essential to the continued success and progress of CAHs.

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Flex program criteria2

To participate in the Flex Program and receive reimbursement as a CAH, the facility must:

  • participate in Medicare.
  • meet Medicare conditions of participation.
  • operate in a state with a participating Flex Program.
  • be located in a rural area at least 35 driving miles from another hospital, or within 15 driving miles by secondary roads or in mountainous terrain.
  • have at least 25 beds, including acute and swing beds (beds that may be utilized as either acute or skilled care for Medicare patients who've stayed 3 or more days if certain conditions are met).
  • maintain an average length of stay of 96 hours.
  • provide emergency services 24 hours per day, 7 days per week.
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1. Rural Health Information Hub. Critical access hospitals. 2018.
3. H.R.2015—Balanced Budget Act of 1997. 2018.
4. American Hospital Association. Critical access hospitals. 2017.
5. Department of Health & Human Services. Rural Health & Primary Care, 1. CAH Provision of Services Standards and Certification. 2014;79(91):27,127-130,131.
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8. The National Academies of Sciences Engineering Medicine. Quality through collaboration: the future of rural health (2005). 2018.
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10. FLEX Monitoring Team. Critical access hospital locations. 2018.
11. Rural Health Information Hub. West Virginia. 2017.
12. United States Census Bureau. QuickFacts: Braxton County, West Virginia; West Virginia. 2016.,54.
13. Weden ML. The Joint Commission vs. CMS requirements: what's the difference? 2015.
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