Holes in the safety net: The impact of rural hospital closures on pre-hospital emergency care

A few weeks ago Lee County Hospital Authority ended negotiations with Florida-based startup Americore Health to re-open the county’s only hospital in a rural corner of southwest Virginia. Wellmont Health System had previously shuttered Lee County Regional Medical Center in 2013, citing a lack of patients and declining federal reimbursement for care services. LCRMC’s closure resulted in residents either traveling out-of-state or up to 55 miles to the next-closest Virginia hospital for acute services.

The Lee County Hospital Authority and the broader community’s efforts had intended to stem a growing trend over the last decade - rural hospital closures in America.

As with many trends in healthcare, rural hospital closures have ebbed and flowed. Between 2013 and 2017, the U.S. GAO reported that 64 rural hospitals closed - and that nearly half ceased to offer any type of healthcare services after closing their doors. This number of closures was reported to be more than double that of the previous five-year period.

Contributing factors for rural hospital closures have been widely studied by the GAO, The Henry J. Kaiser Family Foundation, analytics firms, and many others. Most generally cite decreasing patient volumes, unfavorable reimbursement rates, and business decisions related to market competition and unsustainable operating models as driving forces for the current trend.

The impact of rural hospital closures has also been examined - notable findings include reduced access to care, outmigration of healthcare providers from communities, and consumer decisions to delay much-needed preventative and chronic care services (perhaps miscalculating the opportunity cost of missing a day of work for a 30-minute appointment).

An area of this trend that I propose requires more study is the impact on pre-hospital emergency care. Emergency care is part of a community’s safety net of core services, and of equal importance as fire and police services. Without basic emergency medical services, reduced access to life-saving, evidence-based healthcare from paramedical professionals can have a significant impact on the severity of and mortality for acute and chronic conditions.

“Rural hospital closures put a burden on pre-hospital care providers and create increased wait-times for patients seeking access to emergency care. Prolonged transport times to more distant hospitals can also cause a community to be without qualified pre-hospital care providers should another emergency event arise,” reported Marc Wtulich, RN, EMT, former Captain and President of Vernon Township Ambulance Squad and Delegate to the 12th District EMS Council of New Jersey. One of Wtulich’s local rural hospitals had closed in 2012, predicated on similar conditions as outlined in studies cited above.

Likewise, the effectiveness of pre-hospital care transformation interventions in response to this trend warrant study, curation, and a national dialog on methods to enable spread. Some tactics that have been promoted or implemented include:

• Public investment in more robust ambulance services. After Mercy Hospital closed in 2015, the city of Independence, Kansas purchased two additional ambulances and hired more EMS personnel. The city of Fulton, Kentucky responded similarly after the closure of Parkway Regional Hospital that same year by supplementing emergency services with city and county funds.
• Opening and operating “Primary Health Centers” to shift focus towards outpatient and transitional care services. This model has been championed by the Kansas Hospital Association but would require licensure and reimbursement changes in order to become a viable option. KHA’s proposed model includes 24 hour-per-day, 7 day-per-week centers which would likely be equipped to handle common medical emergencies.
• Utilization of drone technology to supplement transportation of lifesaving equipment, medicines, and telemedicine capabilities to emergency scenes. According to Michael Van Poots, PhD, NRP, vice president of Harrisonburg Rescue Squad, Inc., in Harrisonburg, Virginia, “When a provider utilizes drones in EMS, improvements in response time, medical sample transport time, traditional aeromedical barriers, and access to emergency care are demonstrated.  Advances in drone technology, improved reliability, and proliferation have made drones worth considering in EMS.”
• Expanding use of telemedicine in pre-hospital care delivery. There have been several anecdotal success stories of EMS utilizing virtual health to reduce unnecessary transports. Theoretically, a “treat and street” care model delivered by EMS personnel would reduce the amount of time these resources are tied up in non-emergent trips.

While Medicaid expansion under the Affordable Care Act has slowed the rate of hospital closures in some rural areas, this trend is obviously only seen in expansion states. Ongoing economic pressures, general trends in rural populations’ health needs, and unabating market consolidations will likely continue to stress pre-hospital emergency care systems in rural areas. Joint public/ private endeavors, federal assistance through CMS’ Innovation Center, and out-of-the-box thinking will be required to understand the impact on EMS and transform emergency care delivery models if we are to provide 21st century prehospital care.

Read more:

The Commonwealth Fund (2017). The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal. Retrieved from: https://www.commonwealthfund.org/publications/issue-briefs/2017/may/impact-acas-medicaid-expansion-hospitals-uncompensated-care

The Henry J. Kaiser Family Foundation (2016). A Look at Rural Hospital Closures and Implications for Access to Care: Three Case Studies. Retrieved from: https://www.kff.org/medicaid/issue-brief/a-look-at-rural-hospital-closures-and-implications-for-access-to-care/

iVantage Health Analytics (2016). Rural Relevance: Vulnerability to Value. Retrieved from: https://www.chartis.com/resources/files/INDEX_2016_Rural_Relevance_Study_FINAL_Formatted_02_08_16.pdf

relyMD (2017). EMS Telemedicine, An Aid for Rural Areas Impacted by Hospital Closures [blog]. Retrieved from: https://relymd.com/blog-ems-telemedicine-an-aid-for-rural-areas-impacted-by-hospital-closures/

U.S. Government Accountability Office (2018). Rural Hospital Closures: Number and Characteristics of Affected Hospitals and Contributing Factors. Retrieved from: https://www.gao.gov/products/GAO-18-634

Medicaid Expansion Outlook in 2019

Bending the cost curve through improved access and quality

Earlier this month the newly-elected governor of Maine, Janet Mills, signed an executive order to begin the process for expanding the state’s Medicaid program. Maine voters had approved Medicaid expansion more than a year ago, but enacting the program had been blocked by then-governor Paul LePage.

Governor Mills’ action brings the count of states without expanded health coverage down to fourteen. Notable hold-outs for expansion include a block of states in the southeast and four that are among the U.S. Census Bureau’s top states with the highest rates of poverty.

While the typical lightning rod issue of the Affordable Care Act (ACA) is often the coverage mandate, Medicaid expansion is probably a close second. The expansion provision was designed to reduce the number of uninsured by offering coverage for low-income adults at up to 138% of the federal poverty level. Following the 2012 Supreme Court decision on the ACA, states were faced with making their own decisions about whether to adopt the expansion and when.

In addition to Maine four other states will be enacting Medicaid expansion in 2019. This includes Virginia, where the tide of voter opinion on healthcare issues made opposition to expansion an untenable position for several in the commonwealth’s legislature. A common rebuke in Virginia was similar to what former Maine governor LePage would claim - that of the “hidden costs” of expansion.

However some would counter that the costs of not expanding access to affordable healthcare are hidden in plain sight, and few would disagree that more can be done to create healthier communities.

As of this writing there are over 200 published works that have studied the effects of Medicaid expansion in the “early adopter” states (Antonisse, et al., 2018). For those still on the fence about Medicaid expansion, I would like to share what the research evidence tells us about the effects of increasing access to healthcare on cost and consumption through the experience of states that have been on the leading edge of this effort.

Myth #1: There is no evidence to support the claim that Medicaid expansion will improve health outcomes or lower costs.

Fact: In Medicaid expansion states, increased coverage rates have improved care access, resource utilization, and affordability for low-income populations, with a disproportionately positive effect in rural communities (Antonisse, et al.). Medicaid expansion has also increased coverage and access for care to pediatric and behavioral health populations (Hudson and Moriya, 2017, and U.S. GAO, 2017), two vulnerable populations in our communities that are commonly underserved (with sometimes disastrous effects in our communities). Need further proof that expanding coverage improves quality and cost? In Medicaid expansion states, infant mortality rates have dropped, while in non-expansion states they have risen (Bhatt and Beck-Sague, 2018).

Myth #2: Medicaid expansion will cause hospitals’ emergency departments to become overrun with non-emergent visits.

Fact: A research study in Maryland found there was no relationship between Medicaid expansion and changes in emergency department (ED) volume (Klein, 2017), and a separate single-facility study found that there were statistically significant reductions in ED visits for ambulatory sensitive conditions and high-utilizers (Gingold, et al., 2017).

Myth #3: There are so few providers that accept Medicaid, the newly-insured will wait months for primary care appointments (if they can find a provider at all).

Fact: Medicaid primary care appointment availability increased significantly in five expansion states, while there was no change in non-expansion states (Candon, 2017). Granted, I doubt anyone would dispute that we have an overall shortage of providers nationally, or that Medicaid is not the most sought-after payor. However, several nationally-recognized, innovative healthcare organizations are actually redesigning their care delivery models and system of services to increase access and efficiency for Medicaid patients... perhaps in some part due to the volume of customers on-hand and the reliability of the payment structure.

In close, the “hidden costs” of expansion are not hidden at all - they’ve always been in plain sight to healthcare providers who see the unfortunate sequelae of poor disease management that results from lack of access to quality, affordable care. What has been hidden, though, are the costs of not exploring and understanding the dynamics that drive care access, utilization, and ultimately cost, quality, and overall community health.

What do you see as hidden costs of current barriers to care access for vulnerable populations?

References

Antonisse, L., Garfield, R., and Rudowitz, R. (2018, March 28). The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. Henry J. Kaiser Family Foundation. Retrieved from: http://www.kff.org

Hudson, J., and Moriya, A. (2017). Medicaid Expansion for Adults Had Measureable ‘Welcome Mat’ Effects on Their Children. Health Affairs, 36(9). Retrieved from: https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0347

United States Government Accountability Office (2017). Medicaid Expansion: Behavioral Health Treatment Use in Selected States in 2014. Washington, DC. Retrieved from: https://www.gao.gov/assets/690/685415.pdf

Bhatt, C., and Beck-Sague, C. (2018). Medicaid Expansion and Infant Mortality in the United States. American Journal of Public Health. Retrieved from: http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2017.304218

Klein, E. (2017). The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments. Annals of Emergency Medicine. Retrieved from: http://www.annemergmed.com/article/S0196-0644(17)30784-9/pdf

Gingold, D., Pierre-Mathieu, R., Cole, B., Miller, A., and Khaldun, J. (2017). Impact of the Affordable Care Act Medicaid Expansion on Emergency Department High Utilizers with Ambulatory Care Sensitive Conditions: A Cross-Sectional Study. The American Journal of Emergency Medicine. Retrieved from: http://www.sciencedirect.com/science/article/pii/S0735675717300141

Candon, M. (2017). Primary Care Appointment Availability and the ACA Insurance Expansions. University of Pennsylvania Leonard Davis Institute of Health Economics (Philadelphia, PA). Retrieved from: https://ldi.upenn.edu/brief/primary-care-appointment-availability-and-aca-insurance-expansions

Make 2019 the Year You Embrace the Agile Nursing Workforce

New Approaches for Addressing a Timeless Challenge

It’s no secret that the nursing workforce has undergone transformational changes over the course of this decade. Whether you believe this is due to generational shifts in the profession, the progression of accountable care and population health models, or the pervasiveness of technologies to support the delivery of care – or maybe all of the above – the current employment environment promotes vertical and horizontal agility for today’s nurses.

Agility, simply defined, represents the power to move quickly and easily. This transformation toward a more agile nursing workforce is often personified through commonly-held observations of the millennial generation. In all fairness, this age group sometimes gets a bad rap – it just so happens that their ability to adapt to industry changes in care delivery, labor supply and demand, and disruptive technology is probably more well-tuned than most. And that’s what happens when agility and change meets structure, rigor, and tradition.

The speed of the healthcare industry to create effective responses for current workforce demands might be characterized as slow at best. Case in point: The continued rise in nursing turnover, which was recently reported at nearly 17% (more than two percentage points higher than 2016 [NSI Nursing Solutions, Inc., 2018]). This may be in part due to confusion about the problem at-hand to solve for. On one hand, the US Department of Labor’s Bureau of Labor Statistics (2018) predicts a 15% growth in nursing jobs through 2026, while another agency projects the actual supply of nurses is expected to exceed demand by 2030 (US Department of Health and Human Services, 2017). In other words, the perceived “nursing shortage” will likely continue to be felt in specific regions (i.e., California and parts of the Southeast) and areas of healthcare services delivery.

Which then begs the question... are you experiencing a true nursing shortage or is yours a problem of attrition? After all, now that millennials comprise more than a third of the nursing workforce, and 17.5% of new nurses leave hospital-based jobs within the first year, maybe the cause of your hypovolemia is simply hemorrhage. And with that kind of problem you might need to get creative to stop the bleeding, especially if what you’ve been doing hasn’t slowed it down.

I’ve always been intrigued by what motivators bring out the best in people and learning ways to create the conditions necessary for that to happen. Over the last few years I’ve spent time both speaking with nursing leaders around the country and researching workforce engagement strategies. While my own leadership experiences haven’t been exclusive to nursing, what I’ve come to believe is that current workforce trends place a premium on an organization’s speed, creativity, and the effectiveness of feedback loops. With this in mind, here are four themes that nursing leaders should act upon in 2019 to prepare for the roaring twenties:

It’s time to double-down on burnout. There’s just too much data out there now to hide from this. A survey by Kronos Incorporated (2017) found that 90% of nurses are considering leaving their hospital for another job because of poor work/ life balance. According to a different survey, the average hospital is expected to lose $4.4 to $7M on nursing turnover, making the return-on-investment for dedicating resources towards burnout clear. Providing lateral mobility for new experiences, structured mentor/ preceptor relationships, and creating meaningful recognition programs that highlight individuals’ contributions and reconnect them to the “why” behind their work will be key in addressing this.

Information can accelerate everything. And using quarterly or annual surveys to drive your engagement and retention strategies is so old school. While I’m always in the front row to embrace benchmarking, traditional survey practices capture “lag” data. By the time you get your results, it’s all in the rearview mirror. Leveraging technologies designed for real-time feedback loops, short and frequent surveys, and “vote to promote” capabilities to surface workplace improvement ideas will put you in the driver’s seat of engagement. Check out what companies like TINYpulse and Laudio are doing in this space for more ideas.

Target high-risk groups with pinpoint accuracy. Armed with better information, customize your workforce interventions with surgical precision. We’d all agree that “one size fits all” doesn’t work – so it’s time to figure out who your at-risk staff are, where and when they work, and why they are a turnover risk. To illustrate this approach, let’s cobble together a risk profile drawn from a few different studies:

• Emergency department nurses continue to be the most mobile nursing specialty. Over the past five years, this group has turned over 102.4% (NSI Nursing Solutions, Inc., 2018).
• 43% of newly licensed nurses who work in hospitals leave their jobs within three years, 33.5% resign after two years and 17.5% work for only one year (PressGaney, 2018).
• 46% of the millennial nurse respondents to the PressGaney survey on nursing workforce resilience (2018) work night shift. This same study also found the lowest levels of engagement with this generation.

While simply an example, data points such as these could create a unique profile for your organization and tailor your interventions and approach to reduce disengagement, burnout, and ultimately turnover.

Get ready to position yourself to be on the receiving end of migratory patterns. A national initiative is underway that is designed to create greater flexibility and workforce mobility through multistate licensure compact. According to a 2018 survey by AMN healthcare, a majority of registered nurses heavily support national licensing, regardless of generational differences. Of the three generations analyzed nearly eight in ten millennials reported wanting to see national licensing. Given that this generation (and most nurses, really) generally seek to improve their nursing practice through education, professional development opportunities, and safe, supportive work environments, those organizations that create desirable cultures and conditions can become a magnet for that migration.

Each of these strategies may be increasingly important for regions with predicted supply-side shortages in the coming decade. In his text Exponential Organizations (2014), Salim Ismail characterized the current dominant generation in the workforce as “... naturally independent, digitally native, and resistant to top-down control.” Creating conditions that reward individuals’ contributions towards a greater purpose, are communicatively agile, and embrace “big tent” innovation through crowdsourced feedback loops are matched strategies to help retain and attract nursing talent into the future.

Healthcare analytics: Embrace all sources to achieve diversity

A few weeks ago I had the opportunity to guest blog on the Premier, Inc. "Action for Better Healthcare" site about a great project we'd completed alongside the leadership team at Good Samaritan Medical Center in Suffern, NY.

This post was a great opportunity to reflect on a project that challenged me to understand & integrate "competing" data sets and navigate the nuances of data credibility... a perception that is often driven by peer norms, professional biases, and natural anxieties that arise when working with unfamiliar data sources and processing methods.

In the end, it's all about the right tool for the job at hand... and building trust among your team that each participant is competent in using the tools they are most familiar with to expand the capacity of your analytics tool belt.

An added benefit: Embracing competing and unfamiliar sources can unlock new insights into the problem at hand... and demonstrates your commitment to collaborative work environments that embrace diverse perspectives.

Post found here: http://actionforbetterhealthcare.com/5-ways-to-show-cfo-return-on-time-investment/

CMS HAC Penalties: Speaking C-Suite Language | Qualis Health Medicare

Great quick webinar from Qualis Health, CMS' Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for the states of Idaho and Washington.  Everyone under the tent of improving healthcare quality should be taking specific steps to move towards understanding others' worldview and perspectives on the topic; doing so will advance us towards a basic common language that describes the economic value-add of high quality.

Speaking C-Suite Language Webinar Presentation Recording | Qualis Health Medicare