This brief reports on a qualitative evaluation of State Flex Program interventions conducted under Program Area 2: Financial and Operational Improvement (FOI), a mandatory area of State Flex Program (SFP) activity. It presents an inventory of all SFP FOI initiatives during FY 15-18 and a more detailed analysis the interventions undertaken by a subset of 14 SFPs.  The FMT explored the types of project proposed by these 14 SFPs and the challenges they faced in monitoring the impact of their interventions on Critical Access Hospital (CAH) financial and operational performance. Efforts to document the impact of SFP initiatives would be supported by:

• Clearer direction on defining CAH participation in SFP initiatives;
• A framework to capture and assess the intensity of CAH participation;
• Instructions on reporting activities properly across the defined activity areas;
• Technical assistance (TA) to help SFPs identify evidence-based initiatives and construct well-developed theories of change and logic models based on the evidence; and
• Development of a defined set of measures to support common SFP initiatives and strategies.