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Presentation to: SORH Working with Vulnerable Hospitals - NORSORHPresented by: Lisa Carhuff – Hospital Services Director

Date: 07 December 2016

Georgia State Office of Rural Health

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MissionThe mission of the Department of Community Health is to

provide access to affordable, quality health care toGeorgians through planning, purchasing

and oversight

We are dedicated to A Healthy Georgia.

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State Office of Rural Health

The programs highlighted today include:• Initial Collaboration – Southern Hospital Sustainability

Committee • Update on Georgia closures• Rural Hospital Stabilization Committee Programs

• Pilot Hospitals • FY17 Hospitals

• Patient Centered Medical Home• Senate Bill 258

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Initial Collaboration

• Southern Hospital Sustainability Workgroup– Alabama– Georgia– Mississippi– South Carolina– Bridget Ware– National Rural Resource Center

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Georgia Hospital Closure Calendar Year End 2016 Update

Hospital Closure List

1. Hancock Memorial Hospital 20012. Dooly County Hospital 20013. Telfair Regional Hospital 20084. Hart County Hospital Hartwell, GA and Cobb Memorial Hospital Royston, GA close and consolidate to Ty Cobb Regional Memorial Lavonia GA – June 2012 – Purchased by St Mary’s (Trinity Health) in 2015 renamed St Mary’s Sacred Heart (net loss 1 hospital)5. Calhoun Memorial Hospital 20136. Stewart-Webster Hospital 20137. Charlton Memorial Hospital 20138. Lower Oconee Regional 20149. North Georgia Medical Center 2016

Closed Emergency RoomFlint River Hospital 2013

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Governor’s Rural Stabilization Committee

• In April 2014, Gov. Nathan Deal announced his appointments to the Rural Hospital StabilizationCommittee, which was created to identify needs of the rural hospital community and provide potential

solutions.“In March of this year, I proposed three revisions to the way we approach rural health care, withone being the Rural Hospital Stabilization Committee,” Deal said. “I recognize the critical needfor hospital infrastructure in rural Georgia and remain committed to ensuring citizens throughoutthe state have the ability to receive the care that they need. This committee will work to increasethe flow of communication between hospitals and the state and improve our citizens’ access tohealth care. I am proud to welcome this team and look forward to what we stand to accomplish.”

• June 9, 2014 – first official convening of Committee

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Initial Stabilization Work - 2014

• Rural Free Standing Emergency Department (RFSED)– Financial modeling– Licensure Regulations approved– Feasibility Studies - evaluated and found to be financially

unsustainable in rural communities• Impact of Obstetrics Closures in rural hospitals • ED Closure and restructure – Mississippi Hospital

Experience Combined two clinics and ER into one hospital-based (HB) Rural Health Clinic (RHC)

• Hearings from closed and financially fragile hospitals

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Rural Hospital Economic Impact

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RHSC 2014 - 2016

2015•RHSC final report published February 23 2015•Based on Committee findings, the “Hub and Spoke” model was determined to potentially provide the most value to rural hospital communities. Emphasis on the delivery of the “Right Care, at the Right Time and in the Right Setting•$3M in funding was requested by Governor Deal and appropriated by the Legislature for the FY16 budget•Pilot hospitals identified by the Legislature•Each received $750,000 and required to provide cash match of $100,000

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HOSPITALS

FQHCsBoard of

Education

CAHs

Public Health

Physicians

Local IndustryTertiary

Hospitals

Nursing Homes

EMS

Home Health

Behavioral Health

Technical Schools

RHSC Hub and Spoke

“the right care, at the right time, in the right setting”

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Appling

Atkinson

Bacon

Baker

Baldwin

Banks

Barrow

Bartow

Ben Hill

Berrien

Bibb

Bleckley

Brantley

Brooks

Bryan

Bulloch

Burke

Butts

Calhoun

Camden

Candler

Carroll

Catoosa

Charlton

Chatham

Chattahoochee

Chattooga

Cherokee

Clarke

Clay

Clayton

Clinch

Cobb

Coffee

Colquitt

Columbia

Cook

Coweta

Crawford

Crisp

Dade

Decatur

DeKalb

DodgeDooly

Dougherty

Douglas

Early

Echols

Effingham

Elbert

Emanuel

Evans

Fannin

Floyd Forsyth

Franklin

Fulton

Gilmer

Glynn

Gordon

Grady

Greene

Gwinnett

Hall

Hancock

Haralson

Harris

Hart

Heard

Henry

Houston

Irwin

Jackson

Jasper

Jefferson

JenkinsJohnson

JonesLamar

Lanier

Laurens

LeeLiberty

Lincoln

Long

Lowndes

Lumpkin

McIntosh

Macon

Madison

Marion

Meriwether

Miller Mitchell

Monroe

Morgan

Murray

Muscogee

Newton

OglethorpePaulding

Peach

Pickens

Pierce

Pike

Polk

Pulaski

Putnam

Quitman

Rabun

Randolph

Richmond

Schley

Screven

Seminole

Spalding

Stewart

Talbot

Taliaferro

Tattnall

Taylor

Telfair

Terrell

Thomas

Tift

Towns

Treutlen

Troup

Turner

Twiggs

Union

Upson

Walker

Walton

Ware

Warren

Washington

Wayne

WebsterWheeler

WhiteWhitfield

Wilcox

Wilkes

Wilkinson

Worth

Dawson

Fayette

Jeff Davis

Stephens

SumterToombs

Rural Hospital Stabilization Pilot Sites – Phase 1

Appling HealthCare SystemCrisp Regional HospitalEmanuel Medical CenterUnion General Hospital

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RHSC Pilot Goals and Implementation Strategy

Goals Implementation StrategyIncrease Market Share Increase community/regional presence

Deploy LifePak 15 EKG to advance STMI diagnosis and appropriate patient destination

Stroke Center & Chest Center Designations Occupational Medicine Level 4 Trauma Designation Tele-nephrology Program

Reduce Medicare Readmissions Mobile Integrated Health Care with EMS &/or nursing staff Case management

Reduce non-emergent care & “Super Users”served in the ED

Case management Telehealth (Nursing Homes, Schools, EMS)

Increase Primary Care Access Develop Patient Centered Medical Home with FQHC School-based health care with direct providers &/or telehealth

equipment

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PILOT PROJECTS

Appling Healthcare• EMS and Emergency Room

Connectivity• School-Based Telemedicine• Occupational Health• Level 4 Trauma Designation• Patient Care Management

Crisp Regional Hospital•Chest Pain Center Designation•School Telemedicine/On-site Clinic•Nursing Home – Advanced Practitioner Placement•Remote Stroke Center Designation•Community Paramedicine

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PILOT PROJECTS & BUDGETS

Emanuel Medical Center

• Tele-nephrology/inpatient dialysis

• Care Coordination• EMS Telemedicine

Union General Hospital• School/Day Care-Based

Telemedicine• Paramedicine Home Visits • Decrease Inappropriate ED

Utilization– Opioid Target– NH Telemedicine

• Tele-neuro/Stroke • Fast Track/Improved ED

Through-Put

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Performance Measures

1. Overall Proxy Measure of Financial StabilizationHub Focus: Meeting or exceeding CY 2014 Net Revenue Community Focus: Decrease total CHARGES for the Top 25 High Volume

(# of admissions/observations for overnight stay) based on the patients living in the defined community (zip code(s)).

2. Access to Care – Inappropriate Utilization of Emergency Department (ED) Care

Frequent flyer utilization (cohort of patients with multiple ED encounters with disposition “discharged” – exclude admissions/transfers).a. Defined by 5 visits or > in calendar yearb. Defined by 10 visits or > in calendar yearc. Defined by 20 visits or > in calendar year

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Performance Measures

3. Readmission Reduction – All Cause Hospital-wide Readmissions – Rate of readmissions within 30 days

4. Mental Health – Average Daily Boarding Hours for 1013 Hold5. Access to Care – Potentially Preventable Hospital Stays

– PQI 90 Ambulatory Care Sensitive Conditions6. Market Share

– Outmigration – Inpatient & Outpatient7. Improved Fidelity – Hospital Consumer Assessment of Health

Care Providers & Systems (HCAHPS)– “Yes, would definitely recommend the hospital”

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Pilot Site Comments

• “This has given us the ability to explore new strategies and care opportunities that otherwise might not have been an option due to lack of capitol and risks”

• We never anticipated the amount of physician opposition to these projects”

• “Although we discussed the need for collaboration, I believe the need is greater than I realized”

• “Change is difficult but necessary for rural hospital survival”• “I spoke in favor of using telemedicine to bring specialty care back to

our community; however, I don’t think I realized how far it could go”• “I hope there continues to be efforts to develop a payment model for

community paramedicine”

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Pilot Site Comments

• “The Pilot Project has been more time-consuming than anticipated”• “We have learned a great deal about our own data.”• “One of our most valuable lessons has been communication and

education regarding our local CSB. We didn’t know them• “You need a physician champion”

• “The project forced me, as a CEO, to look at potential activities for the hospital that I would not have considered, ones which are not either saving us money or generating additional revenue”

• “The Pilot Project has been more time-consuming than anticipated”

• “We didn’t know them and they didn’t know us before now. We are working together for the benefit of our mental patients”

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Challenges We Have Observed…..

•Low volume, Lack of community support•Physician Engagement & Willingness to Change•Community Education & Engagement•Cultural & Lifestyle Challenges•Timely data ~ evaluate, change, adapt, re-evaluate•Connectivity relating to telehealth •Sharing of data… difficult to coordinate care without•Trust Among Community Partners ~ the right care, at the right time…. May not be my place of business

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RHSC FY17 Hospitals

• $3,000,000 Appropriated – Signed by Gov. Deal• 4 Sites Identified• 1 Site Opted Out• $1,000,000 Grants executed – August• Grant Period – August 2016 – June 30, 2018

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Community Health Care Workgroup

Expectations:– Organize, convene the local health care network of spokes; strong

participating presence expected– Engage them in conversations and work to develop partnerships with

mutual benefit– Establish a regular meeting schedule– Share grant funds with partners (spokes)– Recognize that you may not develop a relationship with 100% of those

in your community networks ~ unfortunate reality• Expectation is to try

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RHSC FY17 Hospitals

• Habersham Medical Center – Rural PPS Hospital

• Miller County Hospital – Critical Access Hospital

• Upson Regional Medical Center– Rural PPS Hospital

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RHSC FY17 Hospitals

Habersham Medical Center

• ER Screen / PrimeCare Expansion

• Telemedicine • 340B Pharmacy Program• Community Paramedicine

Upson Regional Medical Center

• Care Coordination• Tele-Medicine• Establish a 10-12 bed

Geriatric Psychology Inpatient Unit

• Student Pipeline for recruitment

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RHSC FY17 Hospitals

Miller County Hospital• Care Coordination Model• Mental Health Collaboration• Emergency Room Redesign

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Patient Centered Medical Home - $300,000

• Legislatively budgeted in FY17 for adoption of PCMH in small rural physician practices– Competitive solicitation– Up to $15,000 per site

What we learned….– Information dissemination

channels were limited– Limited knowledge of

PCMH by rural GA hospitals and clinics

– Perception that application was too difficult (“didn’t even look at it”)

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SB 258 -Tax Credit Program Rural Hospitals

• In order to be eligible for the tax credit program, a hospital must, among other things,-have at least 10% of its annual net revenue categorized as indigent care, charity care or bad debt; and

-file a five-year plan with the Department of Community Health, detailing the financial viability and stability of the hospital.

• Donations received by a hospital under the tax credit program must be used for the provision of health-care related services for residents of a rural county or for residents of the area served by the critical access hospital.

• For individuals, tax credits are limited to 70% of the donation amount or $2500 for an individual and $5000 for couples, whichever is less.

• For corporations, tax credits are limited to 70% of the donation amount or 75% of the corporation's income tax liability, whichever is less.

• Total aggregate tax credits available each year are limited to $50 million in 2017, $60 million in 2018 and $70 million in 2019.

http://dch.georgia.gov/rural-hospital-tax-credit

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SB 258 -Tax Credit Program Rural Hospitals

49 rural hospital organizations determined initially eligible to receive donations

Initial Requirements•FORM 990 (Proxy)•FIVE-YEAR PLAN FOR UTILIZATION OF TAX CREDIT DONATIONS

PURPOSE: The five-year plan will include strategies to address debt, uncompensated care and other challenges to the fiscal viability and stability of critical access and small rural hospitals through the use of tax credit donations.

•DUN & BRADSTREET SUPPLIER EVALUATION REPORTPURPOSE: To demonstrate the hospitals’ financial viability and stability,

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POINTS OF CONTACT

Patsy Whaley Executive Director

State Office of Rural Health229-401-3081

pwhaley@dch.ga.govLisa Carhuff

Director, Hospital ServicesState Office of Rural Health

229-401-3092lisa.carhuff@dch.ga.gov