National Daily Hospital News: National Daily Hospital News Special Report Rural and Critical Access Hospital Optimization Wednesday November 19th, 2025

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National Daily Hospital News

Special Report
Rural and Critical Access Hospital Optimization

SBAR, 5 Successful Case Studies and Project Plan
(United States focus)

Situation

Rural and Critical Access Hospitals (CAHs) anchor care and local economies for roughly 60 million Americans, yet they face sustained financial and workforce pressure: recent analysis finds that nearly half of rural hospitals are operating in the red and more than 430 are at risk of closure. Fierce Healthcare+1

From 2017–2024, 62 rural hospitals closed while only 10 opened, a net loss of 52 facilities; over the longer period from 2005–2024, 193 rural hospitals have closed, deepening care deserts in many regions. KFF+1

At the same time, CAHs must satisfy stringent federal rules: they are limited to 25 acute care beds, must maintain an average acute inpatient length of stay under 96 hours, and must be located a minimum distance from other hospitals, while meeting Medicare Conditions of Participation to be paid at 101% of reasonable cost. Centers for Medicare & Medicaid Services+2Centers for Medicare & Medicaid Services+2

Background

CAHs were created by Congress in 1997 to stabilize rural access after a wave of closures, by offering cost-based reimbursement (generally 101% of reasonable costs) instead of IPPS/OPPS prospective payment—trading higher payment for tight conditions, including the 25-bed cap, 96-hour average LOS, and geographic isolation standards. Centers for Medicare & Medicaid Services+2Centers for Medicare & Medicaid Services+2

Despite this support, financial headwinds have intensified: analyses by Chartis and others show that roughly 43–50% of rural hospitals now run negative margins, particularly in non–Medicaid expansion states, and nearly 200 rural hospitals have closed in the last 15 years. PMC+4Chartis+4Chivaroli Insurance Services+4

New federal and state policy debates—especially around Medicaid funding and rural payment reforms—have raised additional risk. Proposed Medicaid cuts would disproportionately affect rural communities, where up to a quarter of residents rely on Medicaid, and early analyses estimate tens of billions in potential revenue loss for rural hospitals over the next decade if these cuts proceed. National Rural Health+2Center for American Progress+2

At the local level, closures like Glenn Medical Center in rural Northern California, which lost its CAH designation over a 35-mile rule dispute and then closed in 2025, illustrate how technical regulatory decisions can abruptly eliminate inpatient and emergency capacity for entire counties. The Guardian

Implication for leaders: surviving as a rural or CAH now requires deliberate optimization of clinical operations, revenue cycle, and care models (telehealth, swing beds, community paramedicine), grounded in federal rules and local realities.

Action

Across the country, successful rural and CAH optimization efforts share a consistent pattern:

Tighten revenue cycle and cost structure while protecting core services, often with external expertise. Moss Adams
Optimize swing-bed and post-acute programs to fully leverage CAH cost-based reimbursement and shorten LOS in referral hospitals. Stroudwater Associates+1
Deploy telehealth and tele-emergency networks to strengthen ED coverage, sepsis and trauma care, and specialty access without adding onsite FTEs. BioMed Central+1
Extend care “beyond the walls” with community paramedicine and integrated EMS partnerships that reduce avoidable ED use and admissions. Commonwealth Fund
Engage in structured technical assistance and leadership development, often via national rural programs, to build reliable management systems and value-based care capabilities. National Rural Health+1

The following five case studies illustrate how these strategies translate into measurable results.

Results – Five Case Studies

Case Study 1 – Financial Turnaround in a Pacific Northwest Critical Access Hospital

A small Pacific Northwest CAH facing mounting losses partnered with an external advisory firm to overhaul its revenue cycle, chargemaster, and payer contracting while cleaning up legacy system issues after an EHR conversion. Over about 18–24 months, the hospital reduced accounts receivable (AR) days by 28%, stabilized cash flow, and improved net revenue capture, contributing to a sustained positive operating margin and increased leadership bandwidth for strategic initiatives.
Source: Moss Adams CAH financial turnaround case study – https://www.mossadams.com/articles/2024/10/case-study-hospital-financial-turnaround Moss Adams

Case Study 2 – Swing-Bed Optimization at Cox Barton County and Cox Monett (Missouri)

Cox Barton County Hospital and Cox Monett Hospital, both small rural facilities within the CoxHealth system, sought to improve the financial and clinical performance of their CAH swing-bed programs. Working with Stroudwater Associates, they implemented a structured quality reporting program that tracked functional mobility, readmissions, and patient days; aligned workflows across therapy, nursing, and case management; and used data to refine admission criteria and care plans.

Key reported results over the measurement period included:

71.8% increase in swing-bed admissions and 30.3% increase in swing-bed patient days at Cox Monett.
Approximately $120,000 and $200,000 in additional swing-bed reimbursement at Cox Barton County and Cox Monett, respectively.
100% reduction in unplanned rehospitalizations at Cox Barton County and 60% reduction at Cox Monett.
242% improvement in mobility scores at Cox Barton County and 108% improvement at Cox Monett.

Source: Stroudwater case study on CoxHealth swing-bed optimization – https://www.stroudwater.com/case-study/benchmarking-success-how-coxhealth-strengthened-their-critical-access-hospitals-swing-bed-programs-with-stroudwaters-quality-reporting-program/ Stroudwater Associates

Case Study 3 – Tele-Emergency Networks Supporting Rural Sepsis and Trauma Care

A multistate tele-emergency (TeleED) network connecting rural EDs, many in CAHs, to remote emergency physicians and specialists deployed provider-to-provider telehealth for high-risk sepsis and trauma patients. Studies from this network and related tele-emergency initiatives show that telehealth consultations are used most often for the sickest rural patients and are associated with:

Faster time to ED provider evaluation and diagnostic imaging (including CT) for trauma patients.
More timely sepsis bundle adherence and guideline-concordant care in community and rural EDs.

While some studies show similar mortality and hospital-free days overall, subgroups treated by advanced practice providers appear to benefit from lower mortality when tele-ED is used, and economic analyses demonstrate avoided transfers and improved time-sensitive care. Rural Telehealth+2Rural Telehealth+2

Representative source (qualitative TeleED implementation in rural EDs):
BMC Health Services Research – “Managing innovation: a qualitative study on the implementation of telehealth services in rural emergency departments” – https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08271-0 BioMed Central

Case Study 4 – Community Paramedicine Linked to a Critical Access Hospital

In a rural critical access hospital region in the upper Midwest, Mayo Clinic Ambulance’s Community Paramedic Service piloted home visits for high ED utilizers with chronic conditions (including diabetes). Paramedics followed standing orders from physicians to provide medication review, basic labs, health coaching, and social risk screening in patients’ homes.

During a six-month pilot at one CAH, the program was associated with a 59% reduction in ED visits among enrolled patients and high satisfaction from clinicians, demonstrating how community paramedicine can relieve rural ED pressure and prevent avoidable inpatient use. Commonwealth Fund

Source: Commonwealth Fund – “Can Community Paramedicine Improve Health Outcomes in Rural America?” – https://www.commonwealthfund.org/publications/2023/mar/can-community-paramedicine-improve-health-outcomes-rural-america Commonwealth Fund

Case Study 5 – Rural Hospital Turnaround via Technical Assistance and Leadership Development

A Midwestern rural hospital (Scotland County Hospital in Missouri) engaged intensive technical assistance through national rural programs to address chronic operating losses, staffing instability, and service reductions. Over several years, the hospital used data-driven financial planning, board and leadership development, and targeted service redesign to restore positive operating margins, stabilize key clinical services, and rebuild community trust—demonstrating that structured external support and leadership capability-building can reverse decline even in highly vulnerable markets. National Rural Health+1

(Representative source discussing rural hospital turnaround and the NRHA/Chartis rural safety-net work – National Rural Health Association and Chartis rural vulnerability analyses.)

Quality Metrics From These Case Studies

Below are seven metrics drawn from the case studies above, illustrating what “optimization” can look like in measurable terms. Each bullet references at least one underlying source.

28% reduction in accounts receivable (AR) days at a Pacific Northwest CAH after revenue cycle and system-conversion remediation, improving cash flow and reducing financial risk.
Source: Moss Adams CAH financial turnaround case study – https://www.mossadams.com/articles/2024/10/case-study-hospital-financial-turnaround Moss Adams
71.8% increase in swing-bed admissions and 30.3% increase in swing-bed patient days at Cox Monett Hospital following implementation of a structured CAH swing-bed quality reporting program.
Source: Stroudwater/CoxHealth swing-bed case study – https://www.stroudwater.com/case-study/benchmarking-success-how-coxhealth-strengthened-their-critical-access-hospitals-swing-bed-programs-with-stroudwaters-quality-reporting-program/ Stroudwater Associates
Approximately $320,000 in additional annual swing-bed reimbursement across Cox Barton County Hospital (~$120,000) and Cox Monett (~$200,000), demonstrating the financial leverage of well-managed CAH post-acute programs. Stroudwater Associates
Elimination of unplanned rehospitalizations at one CAH (100% reduction) and a 60% reduction at another after swing-bed program redesign and standardized quality metrics, showing that rural post-acute care can meet or exceed larger-system outcomes when tightly managed. Stroudwater Associates
242% and 108% improvements in patient mobility scores at Cox Barton County and Cox Monett, respectively, indicating that clinically robust swing-bed programs can drive functional gains—not just revenue—when therapy intensity and care coordination are optimized. Stroudwater Associates
59% reduction in ED visits over six months for high-utilizing patients enrolled in a CAH-linked community paramedicine pilot, highlighting the impact of home-based follow-up on rural ED crowding and uncompensated care. Commonwealth Fund
Documented movement from persistent operating losses toward positive margins for rural hospitals receiving structured technical assistance and leadership development, as reported in national rural safety-net analyses and NRHA-supported case work—demonstrating that governance and management capability are critical clinical “infrastructure.” Chartis+1

All quantitative metrics above are drawn from the cited studies and case reports. Where multiple figures were synthesized (for example, combining reimbursement gains from two hospitals), this is clearly stated; such syntheses should be interpreted as practical estimates rather than formal meta-analyses.

Leadership Project Plan – 16-Week Rural/CAH Optimization SBAR Project

Assumption: Project kickoff next week, Week of November 24, 2025. Adjust dates as needed for your organization’s calendar. Each phase can be accelerated or extended depending on local capacity.

Phase 1 – Launch, Assessment and SBAR Framing (Weeks 1–3)

Week 1 (Nov 24–30, 2025) – Charter and Situation/Background

Confirm executive sponsor (CEO or CNO/COO) and name a Clinical–Financial Dyad as project leads (e.g., CNO + CFO or ED Director + Controller).
Draft a one-page SBAR focused on your hospital:

Situation: current margin, days cash on hand, key service-line threats, workforce red flags.
Background: payer mix; CAH status details (bed count, average LOS, geography); recent capital and EHR changes; any prior turnaround efforts.

Build a core project team (Finance, Revenue Cycle, Nursing/ED, Therapy, Case Management, IT, EMS representative; optional board liaison).
Approve project charter with: scope (hospital-wide, with initial focus on ED, swing beds, and revenue cycle), goals (e.g., +2–3 percentage-point operating margin improvement over 18–24 months), and decision rights.

Week 2 (Dec 1–7, 2025) – Baseline Data Pull
5. Pull 12–24 months of baseline data for:

Financial: operating margin, payer mix, AR days, denials, write-offs.
Clinical operations: ED volume, transfers, LWBS, LOS, sepsis/trauma outcomes.
Post-acute: swing-bed census, LOS, readmissions, therapy intensity, functional scores.

Map data availability and gaps (e.g., lack of standardized functional measures, incomplete transfer records) and define a minimum data set for tracking optimization work.

Week 3 (Dec 8–14, 2025) – Background Deep Dive and Target Selection
7. Compare your hospital’s metrics to national rural/CAH benchmarks and vulnerability reports (e.g., Chartis, KFF, NRHA) to identify top risk drivers (margin, payer mix, workforce). Fierce Healthcare+2KFF+2
8. Select two to three initial focus domains, such as:

Revenue cycle and AR days (Case Study 1).
Swing-bed/post-acute program (Case Study 2).
ED/TeleED and community paramedicine (Case Studies 3–4).

Update SBAR “Background” section to reflect local baseline and external benchmarks; review with executive sponsor and board quality/finance committee.

Phase 2 – Design and Early Action (Weeks 4–8)

Week 4 (Dec 15–21, 2025) – Revenue Cycle & Swing-Bed Diagnostic
10. Conduct a rapid revenue cycle workflow mapping from registration through coding, billing, and collections; document handoffs, failure points, and denial hot spots. Moss Adams
11. In parallel, perform a swing-bed program review: admission criteria, therapy staffing, documentation quality, length of stay, and readmissions; compare your metrics to those reported in high-performing CAH swing-bed programs (e.g., mobility scores, readmit rates). Stroudwater Associates

Week 5 (Dec 22–28, 2025) – Telehealth and Community Paramedicine Readiness
12. Inventory existing telehealth contracts and technology (ED tele-consult, behavioral health, stroke, sepsis) and identify capability gaps relative to evidence-based tele-ED models. Rural Telehealth+1
13. Engage EMS leadership to explore or expand community paramedicine pilots focused on frequent ED utilizers and recent discharges from your CAH. Commonwealth Fund

Week 6 (Dec 29, 2025 – Jan 4, 2026) – “Action” Design Workshop
14. Hold a ½-day multidisciplinary design workshop to finalize your “Action” plan:

Revenue cycle: AR day reduction target, denial work queues, clean claim rate goals.
Swing beds: standardized admission criteria, therapy/functional metrics, readmission reduction targets.
Telehealth & community paramedicine: priority protocols (sepsis, trauma, high utilizers) and activation triggers.

Translate workshop outputs into 3–5 SMART objectives for each domain (e.g., “Reduce AR days by 20% in 12 months,” “Cut swing-bed readmissions by 40% in 9 months,” “Enroll 30 high-utilizer patients in community paramedicine within 6 months”).

Week 7–8 (Jan 5–18, 2026) – Pilot Launch
16. Begin revenue cycle sprints (e.g., fixing registration errors, coding edits, and timely filing issues) with weekly metrics reviews.
17. Launch or expand swing-bed optimization: standardize documentation, schedule therapy to maximize functional gains, implement discharge/readmission review huddles. Stroudwater Associates
18. Activate at least one telehealth protocol (e.g., sepsis or trauma TeleED consults) and a limited community paramedicine pilot for a small cohort, starting with high-risk conditions like diabetes and heart failure. Commonwealth Fund+1

Phase 3 – Scale, Measure, and Lock-in Results (Weeks 9–16)

Weeks 9–10 (Jan 19–Feb 1, 2026) – Early Results and SBAR “Results” Draft
19. Review 30–60-day data from each domain and compare against baselines. Highlight early wins such as reduced AR days, improved swing-bed census, and fewer ED revisits among the pilot cohort.
20. Draft the “Results” section of the local SBAR, mirroring the five national case studies above, with your own before/after metrics, stories, and qualitative feedback from clinicians and patients.

Weeks 11–12 (Feb 2–15, 2026) – Refinement and Spread
21. Use Plan–Do–Study–Act (PDSA) cycles to refine order sets, tele-consult triggers, community paramedic workflows, and discharge criteria.
22. If early results are positive, spread successful practices to additional units (e.g., broader post-acute population, expanded tele-ED conditions such as stroke or behavioral health).

Weeks 13–14 (Feb 16–Mar 1, 2026) – Governance and Sustainability
23. Embed key measures (AR days, swing-bed readmissions, ED revisit rates, functional scores) into your monthly board and medical staff dashboards, with red/green thresholds and owner names.
24. Formalize contracts and MOUs for telehealth and community paramedicine, clarifying financial arrangements, documentation standards, and rural payment implications.

Weeks 15–16 (Mar 2–15, 2026) – Final SBAR, Communication, and Next Wave
25. Complete a comprehensive SBAR report for the board and community, summarizing Situation, Background, Action, and Results, with 6–8 clear charts or bullet lists and 1–2 patient stories.
26. Communicate results to frontline staff, local media, and community partners to build trust and support.
27. Identify the “next wave” of optimization (e.g., OB service stabilization, behavioral health access, value-based care contracts) and begin a new SBAR cycle.