The Flex Program



The Flex Monitoring Team (FMT) is a consortium of researchers from the Universities of Minnesota, North Carolina at Chapel Hill, and Southern Maine. Funded by the Federal Office of Rural Health Policy (grant number U27RH01080), the FMT evaluates the Medicare Rural Hospital Flexibility Grant Program (Flex Program).

Supporting Critical Access Hospitals

The Flex Program supports a specific type of rural hospital, Critical Access Hospitals (CAHs), which are found in 45 states. By meeting specific federal requirements, these hospitals receive CAH designation, allowing them to be reimbursed at 101% of reasonable costs for most inpatient and outpatient services they provide to Medicare patients.


To be designated as a CAH, a hospital must:

  • Be located in a rural area;
  • Be more than 35 miles from another hospital (or 15 miles in areas with mountainous terrain or only secondary roads available, or have been certified as a "necessary provider" by their state prior to January 1, 2006);
  • Provide 24-hour emergency care services;
  • Have a maximum of 25 inpatient beds; and  
  • Maintain an annual average length of stay of 96 hours or less for their acute care patients.


There are over 1,300 CAHs working to improve access to health care services and population health for rural residents across the United States.

To help track the impact of the Flex Program, the Flex Monitoring Team examines data and conducts research on CAHs to assess quality, financial, and community measures at the national, state, and hospital level. The FMT produces a variety of different publications each year on their findings to help State Flex Programs and CAHs optimize their performance.

Our Work

FMT staff aim to improve the accessibility, viability, and quality of health care for rural residents and communities. The FMT conducts analyses evaluating the Flex Program, collects and tracks state-level CAH data, maintains a national listing of CAHs, and maintains and updates the CAHMPAS database, an online data query tool used to explore the financial, quality, and community-benefit performance of CAHs. FMT researchers also work closely with other organizations integral to the Flex Program, including the Federal Office of Rural Health Policy, the Technical Assistance and Services Center (TASC), and the Rural Quality Improvement Technical Assistance (RQITA), to provide services and share findings.

FMT work focuses on three main topic areas: quality improvement, financial and operational improvement, and community engagement.

Quality Improvement


Through the Medicare Beneficiary Quality Improvement Project (MBQIP), CAHs report data on quality performance activities in four different domains: patient safety/inpatient, patient engagement, care transitions, and outpatient. By increasing quality data reporting through MBQIP, the Flex Program hopes to drive quality improvement activities based on the data from CAHs across the country. The FMT tracks CAH participation and performance on these quality measures and produces annual reports, and briefings on their findings in addition to best practices and evaluative analyses.

Financial and Operational Improvement

Finance documents

The Flex Program aims to improve the financial and operational outcomes of CAHs. Through state-wide assessments, action planning, and activities, the Flex Program hopes to identify financial and operational strengths and challenges of CAHs and pinpoint targeted strategies for improvement. To help achieve this goal, the FMT analyzes CAH financial data and produces reports, tools, and other resources for understanding and evaluating the financial condition of CAHs.

Community Engagement

Community Engagement

The Flex Program also works to improve the health of rural communities through a focus on health system development and a community health improvement framework. Through this framework, the Flex Program identifies collective issues and trends in the assessment of local needs as well as the engagement of community members in the prioritization of needs and development of plans and strategies to improve population health. The FMT assesses the community engagement, community assessment, population health and health system development activities of CAHs as well as the integration of Emergency Medical Services into those rural systems of care.