Critical Access Hospitals (CAHs) are essential to maintaining health care access in rural communities but face ongoing financial and operational challenges related to low patient volume, workforce constraints, and reimbursement limitations. Supported by the Medicare Rural Hospital Flexibility (Flex) Program, this brief synthesizes evidence on hospital-level strategies that may strengthen the financial sustainability of CAHs.

We conducted a systematic review of peer-reviewed and grey literature published since 2000 examining financial and operational performance improvement interventions implemented by CAHs and rural hospitals in the United States and other developed countries. Thirty-eight studies met inclusion criteria and were categorized into key intervention areas, including service line optimization, revenue and cost management, technology adoption, workforce strategies, partnerships, and access to capital.

The findings suggest that targeted interventions—such as optimizing service mix, improving revenue cycle processes, implementing innovative staffing and telehealth models, and leveraging partnerships or economies of scale—can contribute to improved financial performance. However, evidence varies widely, and no single strategy is universally effective. Outcomes are highly dependent on hospital characteristics, community needs, and local market conditions.

These results underscore the importance of flexible, context-specific approaches supported by the Flex Program. State Flex Programs and CAH leaders can use this evidence to inform planning, prioritize investments, and support sustainable rural health care delivery.