Critical Access Hospital Case Study

Transcription

1 C A L I F O R N I A F L E X P R O G R A M Criical Access Hospial Case Sudy John C. Fremon Healhcare Disric S E P T E M B E R

2 Is he Medicare Rural Hospial Flexibiliy (Flex) Program and small rural hospials conversion o Criical Access Hospial (CAH) saus improving he qualiy of care and he performance of small rural hospials, enhancing local emergency medical services, and fosering nework developmen? A case sudy highlighing John C. Fremon Healhcare Disric, Mariposa, California, was conduced as par of California s Medicare Rural Hospial Flexibiliy (Flex) Program and is program evaluaion aciviies o examine and repor on hese quesions. C A S E S T U D Y O B J E C T I V E S AND METHODS The John C. Fremon Healhcare Disric case sudy was compleed o idenify communiy, hospial, and oher healh care relaed changes and oucomes ha have occurred due o John C. Fremon Healhcare Disric s conversion o Criical Access Hospial (CAH) saus and is involvemen in he Flex Program as well as o idenify needs and issues for program planning purposes. To accomplish his, he following occurred: Local healh services and communiy background informaion was colleced from June - July 2009 on Mariposa, California. Inerviews of hospial saff, hospial board members, and local emergency medical services (EMS) personnel were conduced in Mariposa June 2 & 3, A survey of healh care providers (e.g., physicians, physician assisans, nurse praciioners, nurse anesheiss) working in John C. Fremon Healhcare Disric was conduced May June The survey response rae was 86.3 percen. A communiy focus group was conduced in Mariposa on June 2, Thiry-five individuals from he hospial service area were included in he case sudy process. The California Deparmen of Healh Services, Sae Office of Rural Healh, adminisers he Flex Program in California and was he sponsor of he case sudy. Rural Healh Soluions, Woodbury, Minnesoa conduced he case sudy and prepared his repor. PAGE 1

3 M A R I P O S A, C A L I F O R N I A A N D T H E S U R R O U N D I N G A R E A Mariposa is locaed a he foohills of he Sierra Nevada mounain range in cenral California abou 165 miles eas of San Francisco, California, 155 miles souh of Sacrameno, California, and 72 miles norh of Fresno, California, along highway 49. I is siuaed ouside of Yosemie Naional Park and serves as a gaeway and base camp for he park. Mariposa is locaed in Mariposa Couny which has an area of 1,463 square miles ha consiss of grasslands, mounain, river, and valley errain. There are no ciies in Mariposa Couny raher i has hree Census-designaed places (Mariposa, Boojack, and Yosemie Valley) along wih oher unincorporaed communiies (e.g., Greeley Hill, Lush Meadows, Oak Grove Esaes). In 2008, here were 17,976 people in Mariposa Couny reflecing an increasing populaion when compared o 2000 daa (17,130). 2 However, comparing his daa o he 1990 populaion (14,302), i is eviden ha recen populaion growh has slowed significanly when compared o he previous decade (4.7% growh as compared o 16.5%). While 2008 daa is no available for he ciy of Mariposa, he populaion was 1,373 in 2000; his is a 19% increase in populaion when compared o 1990 (1,152). 3 Adding o he couny s residen populaion are he approximae 3.5 million people ha visi Yosemie Naional Park on an annual basis. We are cenrally locaed as we are hree o four hours from everyhing. Case Sudy Paricipan Hisorically a mining and agriculural communiy, Mariposa is increasingly an oudoor recreaion area ha offers camping, rafing, skiing, fishing, gold panning, hiking, climbing, mounain biking, and oher aciviies. Tourism is he larges indusry in he area, and he larges employers are Foresry and Fire Proecion, Tenaya Lodge, Wawona Hoel, local school disric, Ahwahnee Hoel, and John C. Fremon Healhcare Disric. Along wih Yosemie Naional Park, Mariposa has a hisoric main sree ha is lined wih srucures from he 1850 s ha remind visiors of he old wes. The ciy boass of having one of he bes small own museums in he US he Mariposa Museum and Hisory Cener - while he couny is one of few in California wihou a sop ligh. 4 2 Source: U.S. Census Bureau. 3 Ibid. 4 hp:// PAGE 2

4 This is one of he nices places o raise a family. I is beauiful, slowpaced, and caring people live here. Case Sudy Paricipan When asked, Wha makes Mariposa a healhy place o live?, case sudy paricipans characerize he communiy as having: clean air, organic farming/gardening where people grow heir own food, no raffic, lile o no sress, many opporuniies for seniors, good waer, friendly people, families spending a lo of ime ogeher, a small-own feeling, a low crime rae, safe, easy access o recreaional aciviies, relaxed, srong sense of communiy wih a lo of voluneerism, and access o local ars aciviies. When asked, Wha makes Mariposa an unhealhy place o live?, case sudy paricipans repor: limied access o specialy healh care/surgery services, lack of coninuiy of primary care physicians, illegal drug use, marijuana planaions, homes ha are no insurable because hey are self-made, eenage drinking, domesic violence, child abuse, low incomes/povery, populaion wih chronic healh care issues, lack of infrasrucure/services (e.g., shopping, heaers), increased opporuniies for severe injuries/accidens/rauma (drowning, falls, moor vehicle), fores fires, limied o no healhy social aciviies for eenagers, lack of economic opporuniies and employmen, and lack of healh insurance. John C. Fremon Healhcare Disric Mission Saemen: To excel in he provision of qualiy healh care services. Porrai of John C. Fremon J O H N C. F R E M O N T H E A L T H C A R E D I S T R I C T John C. Fremon Healhcare Disric is named afer John C. Fremon who lived in Mariposa, was he firs Senaor from California, and was he firs Republican candidae for Presiden. 5 John C. Fremon Healhcare Disric is a 25-bed CAH ha convered o CAH saus July 1, 2001, making i he 5h hospial o conver in California and he 403rd o conver in he U.S (34 hospials hroughou he U.S. were cerified on ha day). 6 The hospial is par of a healhcare disric and offers emergency care and inpaien and oupaien services and i has an aached long-erm care faciliy, deached rural healh clinics (2), a specialy care clinic, hospice, and home healh services. The Chief Execuive Officer has been working in he hospial for less han one year, he Chief Financial Officer 17 years, he Direcor of Nursing 22 years, he Clinic Direcor 20 years, and he Qualiy Improvemen Coordinaor 13 years. The hospial employs 219 people (170 full-ime equivalen employees). In addiion, here are four physician assisans and 69 consuling physicians working a he hospial. Healh care providers surveyed repor hey have worked an average of 5.4 years a he hospial. 5 Source: Wikipedia, rerieved July 21, As of Augus 2009 here are 30 CAHs in California and 1305 in he U.S. Sources: California Sae Office of Rural Healh and Flex Monioring Team. PAGE 3

5 John C. Fremon Healhcare Disric s service area is approximaely 2,000 square miles and includes he communiies of Mariposa, Coulerville, Greely Hill, and visiors o Yosemie Naional Park. This service area populaion of approximaely 5,000 full-ime residens (which can swell o over 50,000 due o ourism and local evens), can be characerized as being poorer, significanly older, more likely o have a high school diploma bu less likely o have a college degree, and significanly less likely o be Hispanic when compared o California s populaion overall. The hospial s 2008 average daily census for acue inpaiens was 2.77 paiens per day and he hospial had approximaely 5,025 emergency room visis and 36,233 oupaien visis ha same year. The nex neares hospial o John C. Fremon Healhcare Disric is Mercy Medical Cener, Merced, California, which is 38 miles souhwes of Mariposa or approximaely 46 minues by road. Ambulance services for he area are provided by Mercy Medical Transporaion, Inc. I provides paramedic services hrough 24 employees rained in emergency medical services (9 paramedic and 15 emergency medical echnicians-basics) and five ambulances. The ambulance serves all of Mariposa Couny and made approximaely 2,000 runs in Their average run ime is 30 minues. Run volume has been increasing over he pas few years (1,800 runs for he firs seven monhs of 2009) bu ambulance saff is no clear as o wha is conribuing o he increase. Over half of all ambulance runs are ransfers wih mos paiens going o Fresno (1.5 hours) or Modeso (1.5 hours), California. PAGE 4

6 I M PA C T O F T H E F L E X The naional Medicare Rural Hospial Flexibiliy Program was creaed as par of he federal Balanced Budge Ac of Is goals are o: 1) Conver small rural hospials o CAH saus 2) Suppor CAHs in mainaining and improving access o rural healh care services 3) Develop rural healh neworks 4) Inegrae EMS ino he coninuum of healh care services 5) Improve he qualiy of rural healh care John C. Fremon Healhcare Disric was seleced for an impac analysis using a case sudy approach in order o examine program oucomes and he impac ha he Flex Program has had on local communiies. Daa were obained from he California Deparmen of Healh Services, Sae Office of Rural Healh and he naional Flex Monioring Team as well as case sudy paricipans. Case sudy paricipans were asked quesions relaed o each of he Flex Program goals, focusing on oucomes, accomplishmens, needs, and on-going issues. Following is a saus repor for each goal, including: goal saus, indicaors for success and indicaors of on-going needs and issues. Alhough many of he indicaors canno be direcly and/or purely aribued o he aciviies of he California Flex Program, case sudy paricipans familiar wih he Flex Program repor ha wihou he Flex Program, many accomplishmens would have been difficul, delayed, and/or no pursued. PAGE 5

7 Goal: C O N V E R T H O S P I TA L S T O C A H S TA T U S Saus: A C C O M P L I S H E D I N D I C A T O R S O F O U T C O M E S A C H I E V E D : John C. Fremon Healhcare Disric convered o CAH saus July 1, I ook he hospial approximaely 18 monhs o explore he CAH conversion opion, complee a financial feasibiliy sudy, work wih Flex Program o prepare for and complee he CAH applicaion process, and o be surveyed and licensed as a CAH. Hospial saff repor hey received CAH conversion assisance from he California Hospial Associaion, California Flex Program saff, and he hospial s accouning firm. Hospial saff repor hey updaed all of he hospial s policies and procedures o prepare for CAH saus. All healh care providers ha are aware he hospial is a CAH indicae hey eiher srongly suppor (76%) or suppor (24%) he hospial s conversion o CAH saus. We I needed CAH saus o say open. Case Sudy Paricipan don know if I d live here if here wasn a hospial. Case Sudy Paricipan All hospial saff inerviewed repor hey suppor he hospial s conversion o CAH saus. Commens/informaion by case sudy paricipans relaed o he CAH conversion process include: Everyone [oher CAHs] old us CAH conversion was beneficial. We received suppor from oher CAHs ha had already been hrough he process. Flex Program grans helped us o pay for key pars [financial feasibiliy sudy] of he conversion process. John C. Fremon [hospial] provides a very criical service o is communiy. Is exisence and sound funcioning is of umos imporance. Closure of he hospial would be a big problem. Where would we go if we needed care fas? PAGE 6

8 Goal: SUPPORT CAHS IN MAINTAINING AND IMPROVING ACCESS TO HE ALTH CARE SERVICES Saus: O U T C O M E S A C H I E V E D / O N - G O I N G N E E D S I N D I C A T O R S O F O U T C O M E S A C H I E V E D : Hospial saff repor he Flex Program funded conference calls are informaive and very helpful. Hospial saff repor ha paricipaion in he annual Rural Healh Symposium is beneficial and allows hem o connec wih heir peers. The hospial is engaged in performance improvemen aciviies including: beginning a sraegic planning process, esablishing a wellness group, offering healhier opions hrough he dieary deparmen, esablishing repor cards ha include oucome measures for employees and he board, and encouraging all saffs paricipaion in performance improvemen effors. The hospial s financial performance has improved since CAH conversion. Indicaors of improvemen include: days in accouns receivable and accouns payable have boh declined, new/expanded healh services have been added, and equipmen has been updaed. Clinic and hospial uilizaion have increased. The hospial increased saff salaries and saff reenion raes have increased over he pas 4 years. The hospial opened a specialy clinic in Mariposa (2005) and a rural healh clinic (RHC) wih a elemedicine componen in remoe Greely Hill (2007). They ve [hospial] definiely goen beer. They have beer equipmen which allows hem o serve he paiens beer and riage more appropriaely. Case Sudy Paricipan The hospial has added healh services such as oncology. The hospial has made several operaional changes such as enering a purchasing agreemen wih VHA, cuing he salary budge by $800,000, and working owards deb consolidaion. The hospial eliminaed communiy services ha were no profiable and didn fi wih is overall mission (e.g., a local handy-man service). PAGE 7

9 The hospial has used Flex Program grans o suppor saff educaion and raining and o upgrade hospial echnology. Healh care providers surveyed repor he greaes accomplishmens of he hospial in he pas five years as: recruiing healh care providers ha provide excellen care, providing access o specialy care services, implemening sricer guidelines for HIPAA compliance, remaining financially viable, growh and developmen of he mammography program, improved imaging and ulrasound services, opening he RHC in Greeley Hill, iniiaing elemedicine services, improved emergency care services, and improved disaser preparedness. 7 Fify percen of healh care providers surveyed repor ha hey are engaged in communiy healh promoion/disease prevenion aciviies, including: healh screening, in-services for saff, healh fairs, school spors physicals, paien counseling, and paien educaion programs. 7 Case sudy paricipans repor he hospial s new chief execuive officer is having a posiive impac on he hospial. Hospial saff repor Flex Program grans suppor heir aendance a meeings, conference, rainings, and workshops are helpful and beneficial. Many agree hey would no paricipae in such aciviies if he funding was no available. Commens/informaion by case sudy paricipans relaed o mainaining/susaining access o healh care services include: I am passionae abou rural healh care because I can make a difference. Case Sudy Paricipan This hospial has come a long ways in 10 years. The nursing home is one of he bes, if no he bes, ha I have ever been associaed. I was glad I ook he ime o aend [Rural Healh Symposium]. Saff have received a lo more auhoriy o hink big picure and make suggesions [for improvemen] even if i was ouside heir scope. We [communiy] have [access o] a good emergency room ha can sabilize people. The new leadership has improved hings a grea deal. Are we good financially? No. Bu we are beer. 7 Heah Insurance Porabiliy and Accounabiliy Ac. PAGE 8

10 I N D I C A T O R S O F O N - GOING NEEDS/ISSUES: I didn know he ins and ous of his hospial. In fac, I didn know anyhing abou i unil I needed o use i. Case Sudy Paricipan Case sudy paricipans repor a need for addiional informaion and updaes on he California Flex Program. Case sudy paricipans agree ha healh care provider recruimen and reenion is he greaes issue facing he hospial and access o healh services in he communiy. Case sudy paricipans repor regular eriary cener (referral hospials) diversion issues. Healh care providers surveyed repor he greaes issues impacing John C. Fremon Healhcare Disric as: healh care provider recruimen and reenion, hiring a permanen physician, finances/ declining reimbursemen, aging/ou-of-dae equipmen, need for expanded eldercare, and a need for a new hospial. Hospial saff repor veerans needing healh services reporedly can only receive hem if provided in he emergency room. This requires ha veerans ravel 70 miles o receive care a he closes veerans affairs hospial. Hospial saff repor a need for board raining bu have no had he funds o suppor i. Two healh care providers repor hey are no aware he hospial is a CAH. Healh care providers repor he greaes healh care issues affecing John C. Fremon Healhcare Disric s populaion as: access o healh services (including menal healh services), uninsurance/under-insurance, oudaed hospial equipmen, subsance abuse, aging populaion wih chronic diseases, difficuly accessing beds o ransfer paien o a higher level of care, sae removing podiary services for aduls wih medical insurance, increasing chronic condiions (e.g., obesiy), and povery. The hospial needs o upgrade is CT (currenly a one-slice). The hospial needs o engage in sraegic planning, including planning for a new/updaed physical plan. Hospial saff repor he hospial s compuer conversion has been challenging. Case sudy paricipans repor California s financial issues have had a negaive impac on he hospial and he communiy as a whole. Case sudy paricipans repor he hospial needs an elecronic medical record (EMR). Hospial saff repor here would be value in offering: a local dieary/ nuriional clinic ha includes nuriion counseling, addiional social work services o address issues relaed o abuse, drug and alcohol reamen programs, hear failure clinic/program, and general healh educaion programs. PAGE 9

11 Case sudy paricipans repor here is a need o increase hospial markeing focusing on he qualiy and availabiliy of services (e.g., oncology) as well as physician recruimen. Case sudy paricipans repor addiional work is needed o improve inernal hospial communicaions. Hospial saff repor a need for gran wriing raining. Communiy members repor coordinaion of care could improve a he hospial. Communiy members repor a need for local access o kidney dialysis, oncology, Alzheimer s, demenia, and youh counseling services as well as healh educaion opporuniies. Communiy members repor having limied access o orhopedic, denal, and ophhalmology services because of he long waiing liss o receive care. Hospial saff repor some communiy members (seniors in paricular) are no accessing healh services as hey are no aware of he programs available o hem. I is difficul o shake a repuaion from he pas. Case Sudy Paricipan Healh care providers surveyed repor, if given a gran for $40,000, hey would use i o: purchase new equipmen (endoscopy, CT, sli lamp and sand), EMR, recrui a physician, provide paien educaion, increase healh care provider pay, increase communiy awareness and markeing, and complee capial improvemens. Commens by case sudy paricipans relaed o mainaining/ susaining access o healh care services needs/issues include: Lack of providers has been an issue forever. We jus can seem o ge pas i. We need o look a some new formulas for physicians. Everyone goes o Merced and Oakhurs. If he providers refer people ou, he people jus go ou [for healh services]. A lo of people hink hey will be ransferred from John C. Fremon [hospial] o anoher hospial and herefore hey don wan o go here. This is paricularly rue for repea cusomers. Mos of he hospials around here, excep for John C. Fremon [hospial] are always on diversion. They may have a bed bu hey don have he saff. I s a small communiy. They are going o alk abou he negaive. The communiy should know we have chemoherapy available locally. I [communiy member] didn know. I know ha he menal healh services are crucial o his communiy and should be srongly suppored. PAGE 10

12 Goal: DEVELOP RURAL HEALTH NETWORKS Saus: O U T C O M E S A C H I E V E D / O N - G O I N G N E E D S I N D I C A T O R S O F O U T C O M E S A C H I E V E D : The hospial is in he process of esablishing a ele-psychiary nework. The hospial is a member of he California CAH Nework (CCAHN). I N D I C A T O R S O F O N - GOING NEEDS/ISSUES: Hospial saff repor here may be neworking opporuniies o enhance services available locally, including hose hrough elemedicine and hose relaed o oncology services. Hospial saff repor here is a need for improved coordinaion beween rural healh organizaions and programs in California. Communiy members repor he hospial could be working more closely will oher local agencies (e.g., sae exension services, business). Case sudy paricipans repor heir may be an opporuniy o creae a local healh nework o foser improved daa racking, case managemen, and o assure paiens are receiving he care hey need. PAGE 11

13 Goal: I N T E G R A T E E M S I N T O T H E C O N T I N U U M O F R U R A L H E A L T H C A R E S E R V I C E S Saus: O U T C O M E S A C H I E V E D / O N - G O I N G N E E D S I N D I C A T O R S O F O U T C O M E S A C H I E V E D : Case sudy paricipans repor local EMS provides high qualiy services and are good o work wih. EMS saff repor having no financial issues. Local EMS repor heir service area has no communicaion dead-zones and all areas have enhanced 911 services. Communiy members repor having a posiive experience wih local EMS services. The hospial s helipor was upgraded. EMS repor he saff is a fully-paid squad wih no voluneers. EMS saff repor hey audi 100% of all paien care repors (PCRs) o deermine wheher EMS proocols were followed. EMS saff repor hey have muual aid agreemens in place wih Tuollami, Oakhurs, Sierra, and Merced ambulance services. 12-lead EKGs are on all ambulances. I hink hey re [EMS] errific. We have an excellen working relaionship wih hem. Case Sudy Paricipan Commens/informaion by case sudy paricipans relaed o EMS: I hink we [EMS] are doing fine. They [EMS] do a errific job. I haven heard anyhing negaive. They re [EMS] grea. I was ranspored one ime and hey did a grea job. PAGE 12

14 I N D I C A T O R S O F O N - GOING NEEDS/ISSUES: Case sudy paricipans repor ha local EMS services are very expensive and unaffordable o many residens ha are uninsured or underinsured. EMS saff repor hey do join raining wih hospial saff relaed o ACLS, PALS, and CPR; however, his has declined. EMS saff repor long wais a referral hospials requiring paiens o remain in he ambulance for exended periods of ime. EMS saff repor hey are soring run daa on disk and sending i o he Local EMS Auhoriy (LEMSA) regional saff as hey have no fully conneced o he Inerne. EMS saff repor hey do no have he lapops needed o sore run daa while in ransi. EMS saff repor hey are no paricipaing in any ele-raining opporuniies. EMS saff repor hey are occasionally ransferring paiens o he Bay Area (165 miles or 3 hours each way). Healh care providers repor a need for EMS saff o leave PCRs wih he paiens upon arrival o he emergency room versus days laer. Healh care providers repor a need for EMS saff o have more discreion o call for helicoper ranspor. Thiry-wo percen of healh care providers surveyed repor EMS issues exis. There is limied access o ambulance fligh services during winer monhs due o inclemen weaher. The local EMS services saff are no familiar wih he Medicare Rural Hospial Flexibiliy (Flex) Program. PAGE 13

15 Goal: I M P R O V E T H E Q UA L I T Y O F R U R A L H E A L T H C A R E Saus: A C C O M P L I S H E D I N D I C A T O R S O F O U T C O M E S A C H I E V E D : Mos case sudy paricipan repor he qualiy and services available a John C. Fremon Healhcare Disric have improved over he pas en years. The hospial is implemening a coninuous qualiy improvemen program. The following oucomes were idenified: billing error rae has declined 75%, few o no EMTALA violaions (as compared o regular violaions in he pas), no ciaion issues during he las long-erm care uni survey (as compared o pas surveys when he long-erm care faciliy was on he verge of closure), and dieary service services are moniored wice a week. Fify-eigh percen of healh care providers surveyed repor he care provided a he hospial as very good and 42 percen repor good. Fory-wo percen of healh care providers surveyed repor he hospial has aciviies in place o improve qualiy of care. The hospial conducs paien saisfacion surveys a all hree clinic sies. The clinic sies have focused on paien waiing imes and racking paien referrals as par of heir qualiy improvemen aciviies. Hospial ransfers have declined, allowing more paiens o remain in he communiy and o receive care locally. We The I are an oasis, a large golden nugge afer a long day of panning, a gem in he Sierra! Residens are exremely lucky o have such a qualiy faciliy a heir fingerips. Case Sudy Paricipan caring hey [hospial] give is remendous. Case Sudy Par icipan have never worked in an employmen seing ha was so supporive o providers providing he bes care possible. Case Sudy Paricipan PAGE 14

16 The clinics conduc medical record char reviews on a monhly basis. The hospial has changed is peer review process. The hospial is working on all of he Ceners for Medicare and Medicaid Services (CMS) core measures. The hospial is no Join Commission accredied bu is working o mee some of heir sandards. The hospial has changed is dieary services offering healhier opions, special requess from long-erm care residens, creaing brochures o inform paiens abou dieary opions and how o make special requess. Communiy members repor all paiens (regardless of payer) are reaed equally a he hospial. We [hospial] are working hard on qualiy, rying o move up o indusry sandards, raining saff as needed, and working on saff Case Sudy Paricipan reenion. Case sudy paricipans repor ha he long-erm care faciliy aached o he hospial provides high qualiy care and mainains a waiing lis due o demand for services. Commens/informaion by case sudy paricipans relaed o improving qualiy of care include: If you have MediCal [Medicaid], you ge reaed jus as good as any oher paien a John C. Fremon [hospial]. The caring hey [hospial] give is remendous. The long-erm care [faciliy] is full here [John C. Fremon Healhcare Disric]. They [residens] live forever because hey ge really good care and are happy. We are ready for a survey every single day. So, we don have o sruggle o ge ready like we used o have o do. I wan people o say, hey wan o be like John C. Fremon Healhcare Disric. The hospial s inciden repors used o be jus filed away. Now here is acually follow-hrough. PAGE 15

17 I N D I C A T O R S O F O N - GOING NEEDS/ISSUES: Hospial saff repor ransfers are difficul/delayed due o he lack of beds in referral hospials. Hospial saff repor a need for qualiy and performance improvemen benchmarking opporuniies. Hospial saff repor qualiy improvemen/daa documenaion issues. The las Medicare survey o occur a John C. Fremon Healhcare Disric s Mariposa rural healh clinic sie was Healh care providers repor ha diabees paiens are no being referred o a podiaris on a consisen basis. Healh care providers are no fully aware of services available in he hospial and he implemenaion of immunizaion proocols. Fify-eigh percen of healh care providers surveyed repor he hospial does no have aciviies or hey do no know if i has aciviies in place o improve qualiy of care. Case sudy paricipans repor a need for an EMR. Hospial saff repor an on-going need for coninuing educaion opporuniies, including hose relaed o rauma care/services. Hospial saff repor a need for an educaion coordinaor. Hospial saff repor healh care providers could be more engaged in he hospial s qualiy improvemen aciviies. Case sudy paricipans repor here are someimes issues wih access o hospial supplies. Case sudy paricipans repor he hospial s pas repuaion has been hard o change even hough he hospial has changed. Case sudy paricipans repor ha alhough hospial saff performance issues have been addressed, addiional work is needed. PAGE 16

18 Communiy members repor mixed informaion abou he qualiy and services available a he hospial. In addiion, hey repor communiy members ypically poin ou/discuss heir negaive hospial experiences as compared o heir posiive experiences. Commens/informaion by case sudy paricipans relaed o qualiy improvemen needs/issues include: People [hospial saff] are handwriing hings and hen yping i ino anoher sysem. When you can ge diapers for nursing home residens, i s a problem. Our hospial had an image, years ago and here were docors who behaved poorly. They are gone bu here are sill people ha believe he hospial has no changed. Some of he people [hospial saff] are compleely five sar and some need some real work. We Long [hospial] sill need ha opporuniy o shif away from having o worry abou survival and insead o hink abou going for he gold. Case Sudy Paricipan live John C. Fremon [hospial]. Los of people would suffer wihou access o John C. Fremon hospial. Case Sudy Paricipan C O N C L U S I O N S This case sudy highlighs many of he local level successes and challenges of John C. Fremon Healhcare Disric and he California Flex Program. Success can be seen hrough he hospial s conversion o CAH saus, expanded access o services, implemenaion of iniiaives o improve he hospial s performance and qualiy, and srong communiy, saff, and provider suppor for he hospial. Meanwhile, challenges cener on healh care provider recruimen and reenion, he long-erm financial viabiliy of he hospial, he need for capial improvemens, including hose relaed o equipmen, planning, purchasing, and implemening an EMR, and improving qualiy of care. Alhough John C. Fremon has made significan progress and has me some of is challenges, addiional suppor is needed o address many of he idenified challenges as well as o assure hey can remain financially viable o mee he healh care needs of an isolaed communiy wih a large ouris populaion in rural California. PAGE 17

19 This repor was creaed by Rural Healh Soluions, Woodbury, Minnesoa - funded by he California Deparmen of Healh Services, Sae Office of Rural Healh, hrough a gran from he U.S. Deparmenof Healh and Human Services, Healh Resources and Services Adminisraion, Office of Rural Healh Policy. PAGE 18