Rural Hospitals (Flex Program)


Critical Access Hospital-Relevant Measures for Health System Development and Population Health

Document Type

Policy Brief

Publication Date



Rural Hospitals (Flex Program), MRHRC, community benefit, rural, hospitals, population health, measures

Funding Organization or Grant

Federal Office of Rural Health Policy


This policy brief describes the development of the health systems development and population health performance measures that will be included in the Flex Monitoring Team’s forthcoming integrated performance reporting system. In addition to reviewing the individual measures that comprise the measures set, we discuss how the measures can help stakeholders benchmark and improve performance by targeting technical assistance and support to CAHs and rural communities. Researchers at the University of Southern Maine's Flex Monitoring team enlisted the advice of a national panel of community benefit, community health improvement, population health, and rural health experts to assist with the development of a set of health systems development and population health measures relevant to the CAH and rural community context. The resulting measures set contains three subcategories of measures, each with a different focus and intended use: (1) charity care and bad debt; (2) community health improvement, essential community health services, and community benefit; and (3) community health needs and issues.


The Medicare Rural Hospital Flexibility Program (Flex Program) was created by Congress in 1997, allowing small hospitals to be certified as Critical Access Hospitals (CAHs) and offering grants to States to help implement initiatives to strengthen the rural health care infrastructure. The Flex Program is administered by the Federal Office of Rural Health Policy within the Health Resources Service Administration, US Department of Health and Human Services. The Flex Monitoring Team, which conducts research and evaluation on Flex Program activities, is a consortium of the Rural Health Research Centers at the University of Southern Maine, University of North Carolina-Chapel Hill, and the University of Minnesota. For more information, visit