Hybrid Health Care Demonstration Project - River Towns Community

Proposal:

Develop a five-year demonstration project that creates a hybrid delivery model of health care in the River Towns community of Westchester County. This comprehensive community-based model, to be designed after the "Hybrid Delivery Models" referenced in the report issued by the Commission on Health Care Facilities in the 21st Century,1 will focus services on primary care and chronic disease management to reduce unnecessary hospitalizations. To comply with the Commission recommendation, the Community Hospital at Dobbs Ferry (CHDF) will close and St. John's Riverside Hospital (SJRH) will transfer 12 beds and operate the model at the Dobbs Ferry site. SJRH will collaborate with community providers and be responsible for reporting on designated benchmarks demonstrating improved health outcomes community wide.

Rationale:

The Commission report "repeatedly identified communities whose needs could be well served with less than a 'full service' hospital but which require more than an ambulatory center…. Most often, the services that required preservation include a combination of emergency or urgent care, ambulatory care… ambulatory surgery and imaging." Other than critical-access hospitals which are unique to rural areas, there are no financially viable health care delivery models that tailor services to target the needs of these communities. Consistent with the recommendations of the Commission, we must consider innovative projects that begin to shift the focus from institution-based planning to patient-centered delivery systems. The Commission recommended that the State and health care industry collaborate to test and develop new "hybrid" delivery models to "advance the achievement of a restructured health care delivery system." These models focus on the development of patient-centered financially viable alternatives that reduce inappropriate emergency room utilization and inpatient admissions through redirection of resources. The River Towns community presents a forum in which to test an alternative model for the delivery of health care: It is a small community where health outcomes can be monitored and improvements can be measured.

Goals and objectives:

The goal of this alternative delivery model is to reduce emergency room use and inpatient admissions for ambulatory care-sensitive conditions. These are conditions for which good outpatient care could prevent hospitalization or for which early intervention could prevent complications or more severe disease. Approximately one in 40 adults experienced a hospital admission for such a condition in 2005-2006 from the catchment area (defined as the nine ZIP codes that account for 70 percent of patients admitted to the CHDF). Though fewer than 4 percent of these admissions were to CHDF, the focus of this demonstration project is patient-centered health care. Accordingly, the goal of the project is to reduce emergency room use and inpatient admissions for residents of the defined catchment area.

Prevention Quality Indicators (PQIs) will be used to measure rates of such reductions throughout the five-year demonstration. Specific reductions in emergency use and inpatient admissions will be set for each of these PQI measures. PQIs are "a set of measures derived from hospital inpatient discharge data to identify quality of care for ambulatory care-sensitive conditions. Even though these indicators are based on hospital inpatient data, they provide insight into the community health care system or services outside the hospital setting. The PQIs represent the current state of the art in measuring the outcomes of preventive and outpatient care through analysis of inpatient discharge data."2

Program content:

This five-year demonstration project will target the River Towns community for the first couple of years, and then be assessed to determine the feasibility of expanding to neighboring communities. The project design is a three-point program of integrated primary care in the emergency room, care management of chronic health conditions and improved access to integrated breast cancer treatment for minority populations. The project will include a highly structured patient management/navigation system and will support close collaborations with community-based physicians to evaluate urgent medical problems with the goal of providing ongoing care in an ambulatory setting. Community emergency services providers, including ambulance workers, will be trained in appropriate medical protocols for treatment of chronic conditions to decrease inappropriate reliance on emergency rooms; early diagnostic and emergency services will be linked to stabilize and triage patients to appropriate services; social service evaluations will be conducted in the emergency department to provide at-home support services to the elderly and infirm to reduce hospitalizations; evaluation of urgent medical problems that frequently occur in the nursing home population will be provided to avoid hospitalizations; and the Ashikari integrated breast care program will be expanded with enhanced outreach, education, screening and treatment for breast cancer. The project will also conduct health fairs and other community prevention initiatives.

Reporting requirements:

A baseline of data on ambulatory care-sensitive conditions (PQI measures), breast cancer incidence and catchment area demographics will be established and used to measure progress in meeting project goals and objectives. Quarterly reports will include but not be limited to:

  • PQI categories (diabetes, circulatory disease, respiratory disease and acute conditions)
  • Breast cancer incidents and outcomes
  • Emergency room visits by diagnosis
  • Emergency room admissions to observation beds by diagnosis
  • Emergency room transfers to other acute facilities by diagnosis
  • Outpatient/primary care visits by diagnosis

Categories and data for annual and other periodic reports will be determined.

Demonstration project conclusion:

Before the end of the five-year period, a full assessment of the project will be completed to determine the effectiveness of this alternate model for health care delivery. Options to be considered include:

  • Institutionalizing the model with a permanent operating license
  • Expanding the model (or a revised version) to neighboring communities
  • Revising the model and continuing the demonstration
  • Terminating the project

The assessment will also inform future policy decisions regarding alternate care delivery models in other areas of the state.

Next steps:

The state Department of Health will continue to work with officials from St. John's Riverside Hospital to determine what governance structure and facility configuration best facilitate success in meeting the project goals and objectives. Hospital staff will develop a workplan and budget for the $7 million grant to support project start-up. To ensure a smooth transition to the new model, a closure plan for Community Hospital at Dobbs Ferry will be submitted.