NH Challenges Spurring Hospital Investments

It used to be that every time someone came into the hospital, the hospital got paid. So the more patients in the beds, the bigger the payday for hospital coffers.

“We’re really sort of moving away from that now,” says Steve Ahnen, president of the NH Hospital Association in Concord. “It’s not about more, it’s about what’s most effective [for the patient].”

The health care landscape across the country and in the state is changing rapidly. As the state’s population is getting older, hospitals need to cater to the aging demographic by adding services they need, such as vascular and rheumetological care. Further, hospitals are seeing more patients, but fewer reimbursement dollars. In response, the care model has shifted from filling hospital beds to finding efficiencies, focusing on prevention and beefing up technology in order to keep more people as outpatients. Add to all of this a dearth of mental health and addiction services that puts hospitals on the front lines of a growing behavioral health crisis.

In response, many of the 26 hospitals across the state are making investments—either in dollars or through strategic partnerships and affiliations—in both long-term planning and short-term fixes to keep everyone afloat in the changing tides of health care.

Between the aging population and studies showing that cancer diagnoses could jump by as much as 45 percent within the next 12 years, many hospitals are directing investments toward strengthening cancer care programs. Elliot Hospital in Manchester has a major multi-year cancer center in the works, says Joe Ingold, CFO. The center, which he believes will cost in the realm of $45 million to $50 million to complete, will be a comprehensive, one-stop shop meant to house all of the Elliot’s cancer treatment services under one roof.

Behavioral Health
There isn’t a hospital in the state that has not been affected to some degree by the lack of mental health services and the surge of opioid addicted patients. That comes down to a systems problem, Ahnen says.

“There are not enough inpatient services to deal with people when they get into crisis and there aren’t enough outpatient services to keep them from escalating to the point where they need those inpatient services,” Ahnen says. “And with drug misuse, it’s the same kind of thing.”

Those services used to exist, Ahnen adds, but they weren’t self-sustaining. That means patients experiencing a mental health crisis wind up in an emergency room. “It’s quite common for behavioral health patients to be kept in emergency rooms for days and weeks at a time,” says Jeffrey Hughes, vice president and chief strategy officer for Wentworth-Douglass Hospital in Dover.

To address this, Hughes says the hospital opened in April a dedicated area for behavioral health patients. “It’s a five bed area [in the emergency department] that allows us to focus on providing much better care, in a much better environment than they had before,” he says.

Ingold says one of the two biggest investments Elliot Hospital has made in recent years has been increasing the capacity of its emergency room. Elliot Hospital is in the process of adding general medical bays to its emergency rooms as well as combination rooms that can be used specifically to accommodate a person in a mental health crisis. Construction is slated to start next year.

The Elliot is not alone. During its emergency room redesign that took place between 2013 and 2015, Cheshire Medical Center/Dartmouth-Hitchcock Keene added private, universal treatment rooms to its emergency department, which replaced curtained, open-bay style treatment space, as well as dedicated behavioral health space that includes a safe shared bathroom with shower. According to Cheshire Medical Center, at the time of the renovation in 2015, the emergency department had seen a 50 percent increase in behavioral health patients in crisis coming into the emergency department.

Southern NH Medical Center, during the past two years, has added more than 24 clinicians to expand its behavioral health support services, as well as a behavioral health administrator to bring the Acute Community Crisis Evaluation Service System (ACCESS), that was previously managed by Harbor Homes, in house. The ACCESS program is staffed by mental health clinicians, who can provide crisis evaluations 24 hours a day, seven days a week. This initiative was in response to the findings of the hospital's 2015 Community Needs Assessment.

J. Tate Curti, senior vice president and COO for Southern NH Medical Center, says the hospital, in the last two years, expanded its Behavioral Health Inpatient Unit from 13 to 18 beds. According to the 2015 assessment, Southern NH Medical Center spent more than $1.8 million on behavioral health services and has seen its behavioral health and ACCESS programs grow 6 to 7 percent.

In addition to changes to emergency departments, hospitals are adding more outpatient behavioral health services. Curti says Southern NH Medical Center has added staff to expand its Partial Hospitalization Program for anxiety and mood disorders and introduced an Intensive Outpatient Program for substance abuse treatment. It also added behavioral health staff to the Center’s primary care offices.

Starting two year ago, Wentworth-Douglass began embedding behavioral health professionals into each of the hospital’s  primary care practices and acquired a private behavioral health practice, Hughes says. “Our behavioral health program has grown tremendously over the last three or four years,” says Hughes.

Similarly, administrators at the Elliot addressed the lack of outpatient mental health services by creating an integrated care program at three of its sites in 2015. Like Wentworth-Douglass, The Elliot added therapists to primary care facilities so patients could have access to a therapist while seeing their primary care providers. According to the Elliot’s Community Benefit Plan for FY2016, The Elliot logged more than 21,800 behavioral health visits in its first year at a cost of just over $727,000.

Outpatient Services
This trend toward outpatient services isn’t relegated to behavioral health. Outpatient services are expected to accelerate over the next several years, says Ahnen of the NH Hospital Association. “When we used to think of hospitals, we used to think of that building you know on the hill that had inpatient beds where you went in case of an emergency, or where you went if you were having a baby, or having surgery or those kinds of things,” Ahnen says. “That’s changed dramatically.”

Whether it’s improved technology and drugs or the explosion of high deductibles and dwindling reimbursements, hospitals are focusing on managing chronic disease and prevention as a way of ultimately keeping people healthy and out of a hospital bed. To that end, hospital officials are investing in urgent care services and satellite primary care practices that can handle the management of common diseases like diabetes, heart disease and obesity.

Ingold says The Elliot is in the process of opening a new medical office complex in Bedford that will include urgent care, a retail pharmacy and a diagnostic lab, as well as primary care, pediatric and family medicine physicians.

Wentworth-Douglass recently opened a primary and urgent care office in Portsmouth, and is creating a Population Health Management Department to improve transparency and accountability by assessing outcomes, Hughes says. The theory is health outcomes can be improved through analyzing data.

Geriatric Care
Granite State hospitals are also responding to an aging population that has specific care needs. New Hampshire is quickly becoming one of the oldest states in the country, according to the U.S. Census, with 16.5 percent of NH’s population older than 65 in 2015. According to state projections, that is expected to jump to 20 percent by 2020, according to state projections and to 28 percent by 2040.

That’s going to mean hospitals will have to respond with more specialized services, says Alex Walker, COO for Catholic Medical Center in Manchester.

For CMC, that has meant enhancing its heart and vascular program with new procedures and technologies such as implants that help with atrial fibrillation and heart failure monitoring, respectively.

Hughes says Wentworth-Douglass, through its collaboration with Mass General Hospital, is strengthening its cardiovascular services. And still other hospitals are adding rheumatology, gastroenterology and oncology services in order to cater to this demographic.

Frisbie Memorial Hospital in Rochester established the first geriatric psychiatric ward in the state in 1984, and with the number of dementia and Alzheimer's cases expected to grow as boomers age, Frisbie has been investing there as well.

Frisbie has doubled the number of acute care geriatric psychiatric beds from 10 to 20 and added geriatric psych specialists, nurse practitioners and physicians. Frisbie also developed an outpatient psychiatric care program.

Partnerships and Affiliations
With health care costs on the rise and fewer reimbursement dollars to go around, Ahnen of the NH Hospital Association says that many of the hospitals in the state have turned to strategic partnerships as a way to keep costs down and add in new programs and services.

One such affiliation has enabled four North Country Hospitals to not only stay open but offer OBGYN, urology, general surgery and orthopedics throughout the region, which could not have been possible previously.

“Small critical access hospitals across the country are closing every month,” says Warren K. West, the CEO of North Country Healthcare, a partnership between Androscoggin Valley Hospital in Berlin, Littleton Regional Healthcare, Upper Connecticut Valley Hospital in Colebrook and Weeks Medical Center in Lancaster. “Our formation was really to save each of the four hospitals.”

The affiliation, among the first in the nation of its kind for critical access hospitals, created a health system with 1,400 employees, making it the largest employer in the North Country and among the largest health systems in the state. “Our job is to really take the cost out of the system so we can be market competitive,” West says. “By joining forces, we can take advantage of economies of scale, take advantage of shared services and group purchasing as a larger unit rather than four individual hospitals.”

West says in its first six months of operation, this has translated to $5 million in savings for the health system just from being able to get cheaper rates on malpractice, liability and employee health insurance, payroll services and even staff reductions through attrition.

North Country Home & Hospice Agency in Littleton affiliated with North Country Health Care in May. West says without the affiliation, the agency would have likely closed.

Similarly, Walker says CMC officials have spent the past four years expanding CMC’s footprint around the state simply by solidifying strategic partnerships.

Most recently, CMC joined forces with Huggins Hospital in Wolfeboro and Monadnock Community Hospital in Peterborough to create GraniteOne Health System. CMC also has a long-standing partnership with the Lebanon-based Dartmouth-Hitchcock Medical Center that allows Dartmouth to offer some services at CMC’s Manchester campus. And in 2016, CMC added Mass General Hospital to its network of affiliations.

Walker says these affiliations have allowed CMC to bring its cardiovascular services—once relegated just to the greater Manchester area—into the rest of the state.

“What it does for local hospitals is it gives them access to really high quality specialists, close to home in local community hospitals in an outpatient setting,” Walker says. “We’re not looking to have every single case or procedure be done at CMC, we recognize the value of delivering health care locally. We’re not looking to command and control.”

Ultimately, Ahnen says, these collaborations allow smaller hospitals and individual practices to leverage resources of partner institutions, invest in infrastructure and technology updates and deliver needed services to their communities.

“When I think about the blue and white ‘H’ signs we see in communities, yes, it’s a sign that says there is a hospital nearby. But it’s really a promise that that hospital holds out to the community,” says Ahnen. “They are promising that [the hospital] is going to be there whatever their need is, no matter what you are, where you’ve been, what’s [in] your wallet. At the end of the day, we have to be ready to serve that community.”