Implementation and Early Results of the Flex Program's Innovative Models Program Area (Briefing Paper #42)

Document Type

Briefing Paper

Publication Date





In the Fiscal Year 2015 Medicare Rural Hospital Flexibility Grant Guidance, the Federal Office of Rural Health Policy (FORHP) added a new, optional program area focused on rural health system innovations – Program Area 5: Integration of Innovative Health Care Models (Innovative Projects). This new program area allowed states to address needs not covered by the other core areas of the grant program and use Flex Program funding to undertake “innovative” projects with their CAH partners to improve CAH quality, financial, operational, population health, and system delivery performance. The intent was to encourage states to test new approaches to supporting CAHs and rural communities that could provide best practice models for other State Flex Programs.

In 2017, the Flex Monitoring Team (FMT) at the University of Southern Maine undertook a 15-month evaluation of the activities under Program Area 5, with a focus on projects involving telehealth, care coordination, and quality improvement. In our January 2018 briefing paper, An Interim Evaluation Report of the Innovative Projects Portfolio of the Medicare Flex Grant Program, we provided an overview of the Innovative Projects proposed by the 16 states, and a more detailed examination of seven states’ projects and their early implementation experience. This paper provides a more detailed discussion of implementation of the Innovative Projects by these seven states and the factors that affected their ability to successfully implement their projects. The final sections summarize evaluation findings, key lessons, and the broader implications for the Flex Program.


  • Initiatives funded under Flex Program Area 5: Integration of Innovative Health Care Models allowed states to work with Critical Access Hospitals (CAHs) and other rural health partners to facilitate their participation in value-based payment models.
  • Initiatives based on successful Flex Program strategies (e.g., development of quality networks) or existing evidence (e.g., Project ECHO) typically had less difficulty with implementation.
  • Working with and securing the commitment of existing CAH and organizational partners were key factors to overcoming implementation barriers.
  • Monitoring program outcomes was challenging due to difficulties specifying interim outcomes achievable within the funding cycle and accessing data for those measures.
  • States interested in developing projects under Program Area 5 would benefit from technical assistance on program planning, logic modeling, and evaluation.


Best Practices, Care Coordination, Community Impact, Evaluation, Health Systems, Innovative Models, Quality Improvement, Rural Health Clinics (RHCs), Telehealth

briefing-paper-42-implementation-and-early-results-of-the-innovative-models-program-area.pdf (302 kB)
Implementation and Early Results of the Flex Program's Innovative Models Program Area (Briefing Paper #42)