Critical access hospitals (CAHs) provide essential access to high-quality healthcare in rural communities. They represent more than 2/3 of all rural hospitals and are vital for ensuring the health of communities that may not have access to larger facilities. Understanding critical access hospitals and their role in rural communities is key to providing quality local healthcare options.

The Centers for Medicare and Medicaid Services (CMS) designate CAH status to eligible hospitals across the country. This designation was created in response to a series of rural hospital closures during the 1980s and 1990s. Since the 1997 Balanced Budget Act, states have been allowed to establish Medicare Rural Hospital Flex Program (MRHFP) state grants. This program reduced the financial vulnerability of CAHs while improving access to care. It also allowed healthcare to remain local instead of shifting to facilities further away.

To do this, CAHs receive key benefits including reimbursement for Medicare services.

How does a critical access hospital serve the public?

CAHs emerged to encourage states to strengthen rural healthcare options for both inpatient and outpatient services. They have more flexibility than other hospitals in staffing requirements. For instance, they must offer emergency services, but they are only required to have at least 1 MD or DO physician. That person is not required to be on site; however, she must be on-call and available to be on-site within an hour.

woman doctor talking to woman patient

CAHs must have nursing staff on site at all times when patients are receiving acute inpatient care. Some states require registered nurses to be on site, but some allow for LPNs to cover this requirement when there are no acute inpatients.

CAH clinical staff provide more than emergency services. They are also often the heart of a community’s acute and outpatient health care. Those in rural areas can receive referrals to larger facilities, primary care for injuries and illnesses, and outpatient care for diagnostic lab testing at CAHs. These facilities are required to have equipment and medications on site for essential medical treatment. They also must have agreements and transportation available for patients to receive care in larger hospitals. 

Critical access hospital designation process

Hospitals that participate in Medicare can become certified as a critical access facility by meeting conditions of participation such as:

  • being located in a state with an established rural health plan for MRHFPs
  • being located in a rural area more than a 35-mile drive (or a 15-mile drive in the case of mountainous terrain or in areas with only secondary roads available) from any other CAH or hospital
  • providing 24/7/365 emergency care services
  • having no more than 25 inpatient beds that can also be used for swing bed services
  • reporting an annual average acute care inpatient length of stay (LOS) of 96 hours or less

Facilities interested in obtaining CAH status reach out to state survey agencies to begin the application progress. From there, state agencies review and forward the application to the regional Center for Medicare and Medicaid Services office.

Next, the CMS regional office authorizes a state agency survey for a given date. Then, the agency will verify if the facility meets federal requirements.

Facilities need to recertify each year and be up to date with any new requirements. Any facility that does not resolve issues quickly may be decertified. Once CAH status is secure, hospitals can apply for cost-based reimbursements, federal grants, and other benefits.

Medicare Rural Hospital Flexibility Program

The Flex Program provides federal grants to eligible states helping CAHs achieve goals. Key areas of participation include:

  • Medicare reimbursement
  • funding opportunities
  • regulation information about CAH designation and Flex program
  • partner organizations
  • operational challenges

Swing beds

Swing beds are beds that can be used either for acute or post-acute care. They are essential for stabilizing healthcare facilities and provide additional financial benefits. They are often used as equivalents to skilled nursing facility care and give flexibility to the facility to meet the unpredictable demands of care.

young nurse with patient

CAHs may have a maximum of 25 inpatient acute care beds. For CAHs that secure swing bed agreements, any bed can be used for either acute care or swing bed care.

How can Harmony consultants serve in a critical access hospital?

If you’re interested in bringing your passion and expertise for non-clinical healthcare to a critical access hospital, we can help. As a consultant for Harmony, you’ll have the opportunity to help make healthcare smarter while developing your own personal career growth in roles such as:

  • CDI Specialist
  • Inpatient Coder/Coder Auditor
  • Outpatient Coder/Coder Auditor
  • Health information management leadership
  • Coding leadership
  • Revenue cycle leadership
  • Clinical documentation improvement leadership

The team here at Harmony works with critical access hospitals across the country. If you’re looking for a life changing role in an organization that values its connection to its community, we can help.

Learn more about possibilities through Harmony here.

How can Harmony benefit a critical access hospital?

From clinical documentation to revenue cycle management, critical access hospitals are vital to rural healthcare. As part of the team that serves in these organizations, you recognize what having local, high-quality healthcare in rural areas means to the people of those communities. You also recognize how the right staffing and consulting solutions can enable your team to better serve your patient population.

Here at Harmony, we understand the challenges critical access hospitals see each day. We stand by your mission to provide care to the people who trust you in their communities. We’re here to support your revenue goals with interim staffing and consulting solutions. These solutions work behind the scenes to help you create – and maintain – a healthier population.

Learn more about how we can empower your critical access hospital here.


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