The Role of Critical Access Hospitals
By Jeni Miller
In rural areas, critical access hospitals (CAHs) provide care to patients who otherwise would have to travel much further for adequate care. According to CMS, these Medicare-participating hospitals must meet certain criteria1 to be designated a CAH, including:
- Located in a state with an established State Medicare Rural Hospital Flexibility Program;
- State designation as a CAH;
- Located in a rural area;
- Located more than 35 miles from the next hospital, or more than 15 miles in an area with mountainous terrain or only secondary roads, or certification as a CAH before Jan. 1, 2006, due to state designation as a “necessary provider” of healthcare services;
- No more than 25 inpatient beds for either inpatient or swing-bed services;
- 96 hours or less per patient annual length of stay for acute inpatient care (excluding swing-bed services and beds within distinct part units);
- Compliance with the CAH Conditions of Participation;
- Furnish 24-hour emergency care services seven days a week.
Challenges for CAHs
Serving in a CAH can be a much different experience than a larger hospital system, or even a hospital in an urban or suburban environment. Due to lack of training and support, even the case management process might not be as seamless or efficient as it is in other settings.
“The biggest challenge for critical access hospitals is that those doing case management have little to no training and wear a multitude of hats,” says Beverly Cunningham, RN, MS, ACM, partner and consultant at Case Management Concepts, LLC. “Their understanding is so limited that they are often not following rules and regulations — and, unfortunately, are often out of compliance with Medicare, Medicaid, and any payor contracts they may have.”
The lack of training is not reflective of a lack of interest for case managers in CAHs. Rather, they are operating with fewer resources than other case management professionals.
“These are small, rural hospitals,” Cunningham explains. “While some may be part of a hospital system, many are standalone hospitals. Therefore, the resources for education are not always as readily available as to those case managers that have a corporate structure feeding them information and providing them mentoring. The standalone critical access hospital case management staff may not have easy access to rules and regulations, and changes that occur in rules and regulations. They may not even know where to look.”
No Structured Orientation
Cunningham’s team has noticed there typically is no structured orientation for case managers in a CAH. Most often, there is only one case manager for the whole CAH.
“The kinds of questions that I get from case managers in CAHs often focus on the case manager not knowing what they don’t know,” Cunningham notes. “They tell us they were assigned to the role, had no orientation, and don’t really know what to do, or even what priorities they should have each day. When a case manager leaves a position, there is no formal process for the next person assigned to the case manager role. They literally are doing the best they can, but CMS, Medicaid, and other payors don’t really care if we are doing our best. They care if we are compliant with their expectations.”
Adding to the difficulty, case managers in CAHs often cover multiple roles in addition to case management. Since small, rural hospitals usually are limited in staff, case managers also may serve as the ED nurse, nursing supervisor, nursing educator, discharge planner, or any other position. Since there often are no social workers available in CAHs, the discharge planning function might be even more comprehensive or time-consuming in a CAH than in other hospitals.
Out of Compliance
Considering all these nuances to the CAH experience, it is no wonder they often are not in compliance with Medicare, Medicaid, and other payors. According the Cunningham, the contributing causes for this noncompliance include:
- Accessibility and availability of rules and regulations;
- Knowing where to find rules and regulations;
- Understanding where to watch for updates and/or changes to rules and regulations;
- Variability in state rules and regulations;
- Comprehension of payor expectations;
- Lack of physician advisor or utilization review committees — the latter of which is a requirement in the Conditions of Participation.
Possible remedies for helping equip CAH case managers to improve compliance as well as the case management process include:
- Raising awareness of free webinars, podcasts, and information regarding compliance issues;
- Collaborating with finance in compliance billing related to utilization management expectations (such as the Two-Midnight Rule);
- Partnering with groups who offer education to CAHs (may be available from state hospital associations or other such resources);
- Educating by case management experts in the field;
- Making available a physician advisor trained in the role.
Cunningham also recommends conducting an annual assessment of compliance for the case management team and hospital leaders, followed by education on expectations of the role, compliance, and finance related to the case management processes.
Case managers in CAH should review the Conditions of Participation for Critical Access Hospitals.2
- Centers for Medicare & Medicaid Services. Critical access hospitals. Page last reviewed Dec. 1, 2021.
- 42 CFR Part 485 Subpart F — Conditions of Participation: Critical Access Hospitals (CAHs). Last amended Nov. 7, 2022.
In rural areas, critical access hospitals provide care to patients who otherwise would have to travel much further for adequate care. Serving in a critical access hospital can be a much different experience than a larger hospital system, or even a hospital in an urban or suburban environment. Due to lack of training and support, even the case management process might not be as seamless or efficient as it is in other settings.
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