The 2019 Flex Program guidance strongly encouraged the use of cohorts, a group of Critical Access Hospitals (CAHs) with similar challenges or needs in a given program area, to focus on quality improvement (QI) initiatives in order to deploy State Flex Program (SFP) funding effectively and meet the needs of the greatest number of CAHs. Through this project, the Flex Monitoring Team will evaluate state strategies to assess QI needs, establish cohorts, and design cohort activities. The project’s goal is to better understand the challenges to implementing cohorts and how those challenges were overcome, what benefits SFPs and CAHs realized through the cohort strategy and through the use of consultants/contractors, how states are monitoring the impact of cohort activities, as well as the overall effectiveness of their strategies. The project will do so by interviewing State Flex Coordinators and stakeholders from cohort hospitals in four to six states with cohort programs.