Dilemma for Small Hospitals

Delivering Quality Care as Costs Escalate

Superintendent Middleton McGoodwin, left speaks with Unity Elementary School Principal Chip Baldwin on the first day of school at the  Disnard Elementary School in Claremont, N.H., on Aug. 26, 2013. Holding the door is Jen Maynard, a speech pathologist at the school.  
(Valley News - Jennifer Hauck)

Superintendent Middleton McGoodwin, left speaks with Unity Elementary School Principal Chip Baldwin on the first day of school at the  Disnard Elementary School in Claremont, N.H., on Aug. 26, 2013. Holding the door is Jen Maynard, a speech pathologist at the school.   (Valley News - Jennifer Hauck) Purchase photo reprints »

Claremont — The hospital emergency room is not the kind of place Middleton McGoodwin makes a habit of visiting.

The 66-year-old Claremont resident is rarely sick and almost never takes time off at work. But earlier this year, a small cut on his elbow “about the size of a baby’s fingernail” hospitalized him for nearly a week.

“I was in trouble,” said McGoodwin, the school superintendent of SAU 6. “It was something that crept up on me.”

Weeks earlier, McGoodwin had struggled through a difficult bout with the flu. By mid-February, he was feeling better, but his immune system was exhausted and unable to defend his body against an infection that developed in the cut. On Valentine’s Day, he visited the emergency department at Valley Regional Hospital, was prescribed medication and sent home. But overnight, his condition worsened and when he returned to the ER the next day, his blood pressure had dropped dangerously low. He was admitted to the hospital immediately and stayed for five days.

More than six months later, he has made a full recovery and has high praise for Valley Regional’s doctors and nurses. He might have gone to Dartmouth-Hitchcock Medical Center 30 miles away, but the urgency of his condition led him to seek care as quickly as possible. Valley Regional was only minutes from his home.

“I didn’t even think about going to Dartmouth-Hitchcock,” he said recently. “I think the advantage was that it was close.”

But in the new era of health care, small hospitals such as Valley Regional are making significant changes in order to keep offering the immediate access to care for patients such as McGoodwin.

The days of standalone community hospitals offering a panoply of care are disappearing, health reformers say. Federal funding cuts and new pressures to be more efficient have posed serious questions for small hospital administrators. Institutions that have existed for more than a century are cutting services, such as delivering babies, that were once seen as vital to the community.

In Maine, the 105-year old St. Andrews Hospital recently announced it would be closing its 24-hour emergency room and will stop admitting patients overnight starting Oct. 1. Instead, the hospital will become an urgent care and rehabilitation center, leaving Boothbay Harbor residents with the nearest hospital 18 miles away. In interviews with the Boston Globe, residents there expressed outrage for what it could mean for their care.

“I’ve been telling people, ‘We need to get real friendly with our funeral director,’ ” Marie Snow, a former hospital switchboard operator, told the Globe.

To be clear, no hospitals in the Upper Valley are closing their emergency departments. Indeed, community hospitals in the region are required to have emergency departments because of their designation as “critical access” hospitals, a federal category for rural hospitals that entitles them to a certain level of Medicare funds.

But funding for critical access hospitals is coming under increased scrutiny from the federal government and many facilities in close proximity to one another — such as Valley Regional and Mt. Ascutney Hospital in Windsor — could be affected.

In order to continue offering certain types of care, hospitals large and small are discussing changes that would have been unimaginable even five years ago, hospital officials said. One-time competitors are talking about sharing doctors, forming collaborations and alliances, and consolidating some administrative functions. Some of these changes are being driven by reforms contained in the Affordable Care Act, otherwise known as “Obamacare,” as well as potential threats to funding. But they are also coming from a broader realization among health care providers about the need to lower costs by keeping people healthy and out of the hospital, rather than treat them only when they get sick.

“The federal health reform law provided incentives, but in reality, we need to find ways of reducing the cost of care and improving outcomes,” said Steve Ahnen, president of the New Hampshire Hospital Association.

New London Hospital is seeking the state’s OK for a formal affiliation with Dartmouth-Hitchcock. If approved, the affiliation would allow the two hospitals to pool resources, such as sharing billing services, as well as expand clinical offerings and take a more regional approach to caring for patients in the Granite State. Dartmouth-Hitchcock has also partnered with three hospitals in Coos County — Androscoggin Valley Hospital, Weeks Medical Center and Upper Connecticut Valley Hospital — to collaborate on radiology services for patients in the north country.

“I think the pressure on the small hospitals is very significant,” said Roland Lamy, business development leader at Dartmouth-Hitchcock. “They have figured out they need to find a better way of doing things and they are provoking a lot of the conversation. I’ve sat around tables with CEOs of the critical access hospitals now and the conversations in the last year or two are something that I’ve never seen before.”

“We recognize that the environment is changing,” said Anne Holmes, chairwoman of the New London Hospital board, during a public hearing on the D-H affiliation in March. “Free-standing hospitals are pretty much alone in the world and you really need to be part of a system.”

The new model, however, is not necessarily one where a large tertiary care facility like DHMC will be the mothership for the smaller nodes of care at community hospitals, said Gregg Meyer, executive vice president for population health and the chief clinical officer at Dartmouth-Hitchcock. As in McGoodwin’s case, proximity for patients is important.

“Convenience is important and access to timely care is important,” he said. “We have major parts of this region where people, one of their concerns about going to see a health care provider is do they have the money for the gas. I don’t think that centralizing everything in one hub is the model.”

Although some of this collaboration is aimed at allowing small hospitals to keep offering certain types of care, these institutions will have to shed some services. Many changes will not be popular.

In January 2012, Valley Regional closed its birthing unit. The decision came after years of declining birth rates that made obstetrics financially unsustainable. The hospital lost $1.3 million in 2011 providing obstetrics care, midwife services and operating the birthing center, Valley Regional officials said at the time.

A year and a half later, CEO Peter Wright said he still hears complaints about closing the birthing unit from Claremont residents.

“Every single time I go out,” Wright said recently.

Wright, who was hired this year, wasn’t involved in the decision to close it. He says there is nothing that he would like more than to bring obstetrics back to Valley Regional because “it’s the one and only reason that anybody goes to the hospital for a positive reason.” But he understands why Valley Regional eliminated the program.

The hospital was only delivering 150 babies a year. That is not enough volume to justify it financially. The low numbers also threaten the quality of care. The more procedures nurses and doctors perform, the better their skills become, Wright said. If the volume isn’t there, then the staff may not be getting the repetition needed to keep their skills high.

“There’s no bigger advocate than me (for obstetrics),” he said. “But my job as administrator, I need to make sure that the care is safe, that we’re competent at what we do.”

At the same time, Valley Regional is exploring the addition of services, Wright said. For example, there is a huge need for mental health care in Sullivan County and throughout state of New Hampshire, as hospitals emergency departments are crowded with people in psychiatric crisis. Two weeks ago, the number of people in hospital emergency rooms around the state waiting for transfer to the New Hampshire Hospital hit 47 people, eclipsing a previous record of 44 set in February this year, according to the Concord Monitor.

“It’s such an epidemic, I think we have to take a look at what can we do. Can we provide behavioral health services? I don’t know,” Wright said. “I don’t know how we would do it clinically and I don’t know what the economic model is, but I think that we’re forced to take a look at whether that’s possible.”

Valley Regional has existed for 120 years and will remain a hospital for the foreseeable future, Wright said. But the hospital “can’t be everything to everybody” the way it used to be, Wright said, which is why it will be a very different place than it has been in the past.

“We can’t afford to be flexible. Flexible is too rigid,” Wright said. “We’re going to need to be fluid. The change that’s coming over the next couple of years is going to come fast and furious...We’re going to become a very dynamic organization and what we become over the next six months may be different than what we’re going to be in two years.”

Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.