Community decision-making about critical access hospitals: lessons learned from Montana's Medical Assistance Facility Program.

Limited-service hospitals have been used as a means of maintaining health care services in rural communities with full-service hospitals at risk of closure. The Medical Assistance Facility (MAF) limited-service hospital model has been implemented in 12 communities in Montana and has been evaluated by the Health Care Financing Administration as a viable alternative to a full-service hospital in frontier communities. The 1997 federal Critical Access Hospital (CAH) legislation is the most recent nationwide alternative for maintaining health care in rural communities, and it incorporates many of the features of the MAF model. The purpose of this study was to examine rural community decision making regarding MAF conversion from the perspectives of key informants who were involved in the decision-making process. A descriptive multiple case study design was used. Data were obtained through interviews with community members during site visits. The research focused on identification of local issues that were influential in the decision to convert to or reopen as an MAF, features of the MAF model that made it a locally acceptable alternative, and elements that characterized the decision-making process. The issues found to be influential in the conversion decision and the features that made the MAF locally acceptable were those that made the provision of basic services more stable and sustainable. The study suggests that programs to maintain health care services in isolated communities should allow for and encourage an expanded role for nonphysician providers. The lessons learned from the communities included in this study are instructive to rural communities nationwide that are considering a CAH as well as to policy-makers, researchers, and regional and national health care decision makers.