Could new hospital model work?
When the Greater Gilmer Joint Development Authority turned in its appeal and supporting documentation seeking a hearing before the state Department of Community Health in late May, board members cited a task force formed by Gov. Nathan Deal.
The Rural Health Stabilization Committee created by the governor recommended against exactly what the authority is appealing – that a freestanding emergency department at the closed North Georgia Medical Center does not have the numbers to make it work.
Nonetheless, Piedmont Mountainside Hospital plans to open an emergency department in the North Georgia Medical building Nov. 1.
If that happens, the JDA believes Piedmont Mountainside – under the auspices of Piedmont Health Systems in Atlanta – will allow the critical certificate of need to lapse, meaning it will be extremely difficult for an outside entity to build a new hospital in Gilmer County.
Instead, the JDA suggests in its documentation that a “hub and spoke” model of health care being piloted in four rural Georgia counties could conceivably work here. That model emphasizes a rural hospital, or even one smaller with minimal overnight bed space, that can work as a hub that is linked with spokes such as existing health care clinics, schools and fire stations.
The Times-Courier made an effort to contact all four hospitals to enquire how their hub and spoke model was working, with only one responding. However, it should be noted the hub and spoke models are all operating in counties where a hospital is currently open, not closed like North Georgia Medical Center in Ellijay.
The closest pilot
The closest pilot program is Union General Hospital in Blairsville. Union General’s “spokes” include the Walmart pharmacy, physicians’ clinics and a dialysis center, among others, according to a spokeswoman.
Leslie Daniel, public information officer and project manager for Union General, noted all four hub and spoke pilot hospitals are similar and have been trying the concept around a year.
“We all have nursing homes, and we all have certain things that are alike,” she said. “So we’re trying to pilot to see the best way to keep rural hospitals thriving. (The) spokes could be the county health department, our EMS, the fire department – any (entity) that is directly affected by a patient and their care ... in Union County, we own two rural health clinics.”
Daniel said Union General has five different projects within their pilot.
“Some of them are better than others,” she said. “We did a school telemedical program, and we needed to start it at the first of the year rather than the middle of the year, so that was a challenge. Maybe this year that will work better. The school program (works like) a child can come to a school nurse and be seen by one of our physicians in a rural health clinic without having to be taken out of the school.
“Our (emergency room) utilization has been wonderful, we did several things with that. Yes, there’s been good aspects of it and there’s been some disappointing aspects of it, which is typical with a pilot (program).”
Daniel was asked if the hospital reported its outcomes.
“Yes, we have to send to the state Office of Rural Health (of the Department of Community Health) each quarter what we have done,” she said.
In January, Union General reported its findings after six months to the Department of Community Health.
“In 2014, the majority of discharges generated by residents of Union, Towns and Fannin counties were covered under Medicare (54.2 percent),” Union General representatives reported. “There is a large Medicaid and indigent population in the area, as Medicaid and self-pay discharges accounted for 23.9 percent of the total.
“We have already seen an almost 50 precent reduction in unnecessary (emergency department) visits from the focus group with our initial interventions, and expect this to continue to decline.”
Though not mentioned specifically as spokes, Emanuel Medical Center in Swainsboro noted their “team” included two colleges and a telephone company, showing a community-wide effort to get behind the pilot program. The other two hospital pilots for hub and spoke are Appling HealthCare System in Baxley and Crisp Regional Health Services in Cordele.
Other suggestions for spokes in the pilot hospitals are smaller critical access hospitals, ambulances that are WiFi and telemedicine equipped, school clinics that are telemedicine equipped, federally-qualified health centers, public health departments and local physicians.
Interestingly, in May of 2014 Community Health’s ‘Health Care Facility Regulation Division’ reported the following to the Governor’s Rural Health Stabilization task force: “Regulations were revised to add a new classification for rural hospitals, downgrading their services to become a Rural Free Standing Emergency Department.”
But the Rural Health Stabilization Committee finding of February 2015 notes: “One of the main areas of focus for the Rural Hospital Stabilization Committee was to address Emergency Department (ED) stressors in rural hospitals that can contribute and lead to their closure. In an effort to address this issue, a process to scale down hospital operations and create a stand-alone ED was proposed.
“After testimony and research, it was determined that stand-alone EDs are not financially viable, due to several reasons. There are issues with the reimbursement mechanisms and there are extremely high labor costs and capital investments.
“National trend data also shows most of these being developed in wealthier, suburban areas as opposed to rural areas. It was determined that it takes approximately 15,000 ED visits to break even, which equates to a needed population of approximately 35,000.
“However, Georgia has virtually no rural hospitals in counties capable of supporting an ED without outside subsidies.”
Each of the four “grantees” (hospital pilot programs) received $750,000 and provided a $100,000 local match requirement from the hospital and local governments.
The Greater Gilmer JDA submitted the following two paragraphs in its appeal to Community Health:
“While we cannot endorse the freestanding (emergency department) model which was summarily dismissed by Gov. Deal’s task force, we do feel Ellijay/Gilmer County is a great candidate for the next ‘hub’ in the ‘hub and spoke’ pilot plan detailed in the committee’s findings. Ellijay is positioned about halfway between the Union County (General Hospital) pilot site and the health systems of metro Atlanta.
“Being on the (Highway) 515 corridor, at the intersection of state Highways 52, 382 and 282, our community is truly at the crossroads of the north Georgia region. Many of the elements of the ‘hub and spoke’ model are already in place in our community, and we are eager to work toward what might now be lacking.”
Three more pilots funded
State Rep. Terry England (R – Auburn), who has taken the lead in addressing Georgia’s rural health care crisis, responded to a Times-Courier query about hub and spoke funding.
“We actually did include money for three more pilots this year and are continuing to work with the four from last year,” he said in an email. “It is almost a case-by-case model, as we have found, due to each community being so different. We are taking what we learn, though, and then using it as a best practices model for all rural hospitals to follow in the future.”
A request for an interview with the director of the Office of Rural Health about the hub and spoke model was answered with the following emailed response:
“We respectfully decline participating in an interview as this is an ongoing appeal,” said Lisa Marie Shekell, director of Communications and Legislative Affairs.