RCAH Quality Improvement and Patient Care

sections on this page

Antibiotic Stewardship

Swing Bed Programs

Approaches to delivering quality care for everyone

The state Department of Health’s Office of Rural Health supports Rural and Critical Access Hospitals in the collection and submission of the NHSN Antibiotic Stewardship Survey as well as participation in the University of Washington Center for Stewardship in Medicine tele-antimicrobial program.

If interested in your facility’s data submissions, ASP improvement initiatives, and funding opportunities reach out to Rural Health Systems Program Manager Danielle Kunkel.

Antibiotic stewardship

Antibiotic stewardship is especially important in the context of Rural and Critical Access Hospitals, where limited resources and unique community health needs make the appropriate use of antibiotics a top priority. Rural facilities often serve patients who may not have easy access to specialty care or advanced treatment options. In these settings, the development of antibiotic-resistant infections can have serious consequences—leading to longer patient stays, higher treatment costs, and poorer outcomes. Stewardship helps prevent this by ensuring antibiotics are used only when necessary and in the right way.

These health care systems also care for a high proportion of older adults and individuals with chronic illnesses—populations that are particularly vulnerable to infections. By optimizing antibiotic use, hospitals can reduce the risk of complications from resistant organisms and improve patient safety across the board.

Given the common staffing and infrastructure challenges faced by rural hospitals—such as fewer lab services and limited access to infectious disease specialists—stewardship programs also provide a reliable framework for standardizing treatment decisions. This consistency supports better outcomes even in the face of clinical uncertainty.

Moreover, stewardship contributes to cost savings by cutting back on unnecessary prescriptions and preventing avoidable infections like Clostridioides difficile (C. diff), which can be especially difficult to manage in small hospitals.

Finally, strong stewardship efforts help CAHs meet regulatory expectations from CMS and CDC, and enhance quality performance metrics that are vital to continued funding, partnerships, and community trust. For CAHs, antibiotic stewardship is not just a regulatory box to check—it’s a cornerstone of safe, effective, and sustainable rural health care.

Antibiotic Pocket Guide (PDF)
Core Elements of Antibiotic Stewardship (CDC)
Implementation of Antibiotic Stewardship (CDC)
Antibiotic Use and Stewardship in the U.S. (CDC)

Swing Bed Programs

Swing beds are an optional service that may be provided in critical access hospitals (CAH) that meet the Centers for Medicare and Medicaid Services (CMS) eligibility criteria for CAH designation and swing bed conditions of participation (CoP) described in the code of federal regulations (CFR) – 42 CFR 485.645(a).

When a patient is too acute to go home, but no longer meets the eligibility or medical necessity criteria for acute reimbursement, a physician can choose to swing them into a post-acute or extended care bed. Rather than discharging this patient to a Skilled Nursing Facility (SNF) where they will potentially lose revenue, the hospital can provide SNF level of care while keeping their patient in house and receiving full reimbursement.

Medicare provides reimbursement at 100% for up to 20 days of skilled care within a swing bed. Stroudwater & Associates, along with the University of Minnesota, conducted a national study that showed the average swing bed stay was between 10 and 12 days, allowing for maximum reimbursement the entire stay. Swing bed use has also shown a good return to home rate, reduced readmissions, and reduced emergency room visits.

Swing beds are often used for rehab patients, but there is a plethora of uses that can assist hospitals in leveraging swing beds for increased revenue and improving overall population health within their community. Various examples include long term IV antibiotic administration, newly diagnosed diabetic requiring education and blood sugar regulation, ostomy patients requiring site care, maintenance, and education, and extended wound care.

The reference to a swing bed is a patient care and reimbursement status and has no relationship to geographic location in the CAH.

Swing beds do not need to be in a special section of the CAH and the patient does not need to change locations in the facility because their status changes. A physician must complete discharge orders from acute inpatient care services and then complete subsequent admission orders for swing bed services.

CMS Regulatory Authority and requirements for swing beds

Payment is authorized by CMS under Medicare for post-hospital skilled nursing facility services provided by the CAH if:

The CAH has a Medicare provider agreement
The total number of beds that may be used at any time for furnishing swing bed services or acute inpatient services does not exceed 25 beds
The CAH meets the swing bed

An onsite survey will be conducted by the Department of Health and the CAH must meet all requirements before they can obtain swing bed approval. An additional survey of the swing bed CoP will be conducted for all CAHs approved or pending approval for swing beds.

Limit: 25 inpatient beds

Critical Access Hospitals are only allowed to operate 25 inpatient beds at a time. Inpatient beds may be used for either inpatient or swing bed services. Bed types that do not count towards the 25-bed limit:

Observation beds. Examination, procedure, or operating room tables
Beds in a surgical recovery room used exclusively for patients during recovery from anesthesia
Beds in an obstetric delivery room used exclusively for OB patients in labor or recovery after delivery of newborn infants
Newborn bassinets used for well-baby boarders (Exception: If the baby is being held for treatment at the CAH, their bassinet or isolette does count towards the CAHs 25-bed limit);
Stretchers in emergency departments
Inpatient beds in Medicare-certified distinct part rehabilitation or psychiatric units

Limit: 96 hours per patient

The Social Security Act limits CAH inpatient acute care to 96 hours per patient on an annual average basis. The swing bed concept allows a CAH to use their beds interchangeably for either acute-care or post-acute care. A “swing bed” is a change in reimbursement status. The patient swings from receiving acute-care services and reimbursement to receiving skilled nursing (SNF) services and reimbursement without leaving their bed or the CAH.

The change in status from acute care to swing bed status can occur within one facility or the patient can be transferred from another facility for swing bed admission. It is not necessary for the patient to change location within the CAH but moving to a different location is allowed.
There must be discharge orders from acute inpatient care services and subsequent admission orders for swing bed services. The same clinical record may be used for a swing bed patient, but it must include discharge and admission orders to swing bed services, and the swing bed services must be clearly delineated within the clinical record.
A qualifying 3-day inpatient stay in a participating or qualified hospital or participating CAH is required prior to admission to swing bed status in order for a beneficiary to be eligible for Medicare coverage of post-hospital swing bed care. The 3-day qualifying stay does not need to be in the same CAH as the swing bed admission.
The CAH must have a registered nurse, clinical nurse specialist, or licensed practical nurse on duty whenever the CAH has one or more inpatients including patients in a swing bed receiving long term care services.
There is no length of stay restriction for any CAH swing bed patient.
There is no Medicare requirement to place a swing bed patient in a nursing home and there are no requirements for transfer agreements with nursing homes. While there is no length of stay limit for patients in swing bed status, the intended use for swing beds is for a transitional time period to allow the patient to fully recover, return home, or transfer into a nursing facility.
Swing bed certification is limited to the CAH itself and does not include any distinct part rehab or psychiatric units. Swing bed services may not be provided in CAH distinct part units.