Under the Medicare Rural Hospital Flexibility Program, states with Critical Access Hospitals (CAHs) are eligible to receive federal funds to support hospital improvement. This study finds:

• CAHs typically change activities year to year rather than continue the same activity. Further, in the second and third years of the evaluation period, less than 50% of CAHs participated in a financial or operational improvement intervention.
• Over the three years examined, the typical activity pathway for a given CAH through a performance period is an initial assessment in year one, and an in-depth assessment in both years two and three.
• Compared to CAHs at low risk of financial distress, CAHs at higher risk of financial distress are more likely to participate in financial and operational improvement activities.
• Additional data on the intensity of each CAH activity is needed to determine how Flex resources are distributed among CAHs at higher risk of financial distress.