Public Reports and Testimonies

Remarks by Alan D. Aviles
President, NYC Health and Hospitals Corporation

Good evening, I am Alan Aviles, President of the New York City Health and Hospitals Corporation, our City’s public hospital system. Thank you for being with us tonight for our Manhattan annual public meeting, the last of five borough-specific meetings we convene each year. As always, I am eager to hear what HHC’s communities have to say about our performance, especially during what continues to be a challenging time in healthcare generally and for HHC specifically.

First, let me recognize HHC’s senior executives here in Manhattan. Our hosts this evening are Lynda Curtis, Senior Vice President of the Southern Manhattan Health Network and Steve Alexander, Executive Director of Bellevue Hospital. Also in attendance are Denise Soares, the Senior Vice President of the Generations Plus Network and Executive Director of Harlem Hospital, Robert Hughes, Executive Director of Coler Speciality Hospital and Nursing Facility and our brand new Henry J. Carter Specialty Hospital and Nursing Facility, and other senior leaders from our Manhattan facilities. I thank them for the excellent work they do every day as leaders helping us to render the best possible care to Manhattan residents.

I also want to acknowledge the support and guidance of our Board of Directors, under the leadership of Dr. Michael Stocker. My special thanks to Board members who are here tonight and to the members of our Bellevue, Harlem, Metropolitan, Renaissance, Coler-Goldwater, and Gouverneur Community Advisory Boards, who advocate on behalf of our public system and help keep us grounded and responsive to the needs of our patients and communities.

Hurricane Sandy

Last year, I spoke about the impact of Hurricane Sandy on the city and on HHC. A large number of our employees suffered storm-related effects as many found it difficult to get to work because of transportation disruptions and fuel shortages, and some experienced personal hardships that were storm-related.

Tonight, we meet at one of the HHC facilities that suffered severe damage during Hurricane Sandy.

Bellevue Hospital lost power, water, heat, and experienced major flood damage in its basements and mechanical spaces. The hospital was forced to evacuate 700 patients. Thanks to our extraordinary staff, patients were evacuated safely and transferred successfully to other hospitals. Following the storm and Bellevue’s closure, many Bellevue staff temporarily relocated to other facilities to continue to care for patients. The emergency department and inpatient services at Bellevue were not operational for an extended period and many patients were served at other HHC facilities, most notably, Metropolitan Hospital.

By February of this year, all of Bellevue’s services had been restored. Electrical switchgear that was ruined in the basement has been replaced and elevated to the first floor. To help minimize flood damage from future storms, the hospital has installed flood barriers at ramps leading down to its basement-level loading dock, and new quick connections for additional emergency generators are being installed. However, Bellevue still needs to complete the elevation or hardening of other critical systems, including its elevators, water and fuel pumps, as well as its ventilation and air conditioning systems. We hope to complete most of this work in 2014.

At the Coler campus, there was major storm surge damage in its basement and mechanical spaces. As a result, there was a loss of power and steam heat and more than 100 medically-vulnerable nursing home residents were transferred across the island to Goldwater. Even after power, heat, and hot water were restored and residents repatriated, Coler was forced to rely on emergency generators for several months. The facility did not go back on the Con Ed grid until this past spring. Much work remains to be done at Coler to further elevate its critical systems and to harden the facility so that it could better withstand any future severe storm.

During Sandy, the emergency generators in Metropolitan Hospital’s main building remained above the basement flood waters by mere inches, and thankfully the facility remained operational. However, we were not so fortunate at Draper Hall, an administrative building, which housed medical residents and other employees, in addition to FDNY EMS operations. Draper Hall’s basement was submerged and its electrical and other mechanical systems were destroyed. Work continues in the main hospital building to replace and reposition electrical switch gear, emergency generators, and pumps and motors. At Draper Hall, limited restorations are underway for the return of the EMS station, but otherwise the building remains vacant pending possible future development.

We have had to repair other severely damaged HHC facilities, notably Coney Island Hospital, as well as to temporarily relocate services, including our Ida G. Israel Health Center in Brooklyn and Neponsit Adult Medical Day Program in the Rockaways. In the months ahead we will continue working to make all of our at-risk facilities more resilient to any future severe storm.

The Challenges

As you would expect, the storm added an additional burden to the significant financial challenges we already face. These challenges will continue to intensify as we confront projected reductions in revenue and a daunting budget gap.

Medicaid cuts and reforms in the State’s most recent budget will reduce HHC’s reimbursements from the state by more than $50 million this coming year. Over the past five years, HHC has absorbed Medicaid cuts that now total an astonishing $540 million annually.

In addition, we will receive nearly $10 million less in our annual Medicare revenue going forward as a result of the federal sequester.

In a bit of good news, in November, Mayor Bloomberg added $12.5 million to HHC’s baseline budget for fiscal year 2015 and beyond. This represents funding that the City Council has had to restore to our budget every year to help fund our child health clinics, certain mental health and developmental disability programs, as well as other operational expenses. Now that these funds have been base-lined, we are spared the uncertainty of whether we can persuade the City Council to restore them, given other compelling priorities that always arise.

We are increasingly in an environment where we will be expected to deliver better care, with better patient outcomes, and to do so at lower cost. More and more of our funding will be tied to our ability to accomplish these three things.

While healthcare providers throughout the country are also dealing with these same expectations, the challenges for HHC are greater because we provide care for so many uninsured patients. Indeed, last year we served nearly 500,000 patients without insurance.

As you have heard before, HHC has worked hard to control costs internally. Over the past four years, we have implemented a cost-containment and restructuring plan that, in the aggregate, has reduced our projected budget shortfalls by more than $1.7 billion since FY 2010. As part of that plan, by the start of our current fiscal year on July 1st, HHC also had successfully met its workforce reduction target of 3700 full-time equivalent positions and had done so one full year ahead of schedule. This contributed significantly to an annualized $600 million reduction to our budget gap achieved through reduced expenses and optimized revenue collection.

Most of our workforce reduction has been achieved through attrition, and we have tried to shield direct patient care positions as much as possible. Indeed, we actually have increased our total number of registered nurses slightly during the last four years, despite the overall workforce reduction. It is a credit to our dedicated employees that even with more than a 9% reduction in our total workforce, we have maintained nearly the same service capacity across virtually all care settings.

Going forward, our financial plan assumes another $193 million in savings in FY2014 based on our implementation of remaining restructuring initiatives as well as additional cost containment measures. These measures include, among other things, consolidation of targeted services, more centralized procurement, further improvements in revenue collection, and the maintenance of our lowered workforce headcount. These efforts, when fully implemented, aim to achieve additional savings of $390 million in FY15.

HHC’s senior leadership team has been exploring every possible way to close our budget gap while continuing to provide high quality, safe care to our patients and maintain our capacity to adequately serve the communities that depend on us. That said, maintaining the full scale and scope of current services will become more and more challenging, given the reductions in federal funding that started this year.

Furthermore, under the Affordable Care Act, beginning in 2014 the federal government will make significant reductions in supplemental Medicaid and Medicare funding that supports public hospitals. These cuts increase dramatically by 2017 and ultimately could reduce HHC’s federal funding by more than $325 million annually. Although we are advocating against this destabilizing loss of essential federal funding, there is very little prospect of Congress re-visiting the wisdom of these looming, devastating cuts.

It is important for our communities to understand how serious HHC’s fiscal situation is, and why we have resorted to extraordinary measures such as targeted layoffs, the closure of some small community clinics, and the outsourcing of certain services. And it is important that all stakeholders fully appreciate the forceful advocacy required to secure the funding necessary to preserve HHC’s mission and to enable us to continue to meet community needs. While in the past we have relied on increases in governmental funding to keep our system solvent in the face of rising costs that were outside our control, the current economic conditions at all levels of government, the clamor for reducing healthcare costs, and the gridlock in Washington, will make it extremely difficult to garner significant government support for the foreseeable future.

Our willingness to make tough and, at times, painful decisions has enabled us to avoid closing any major HHC facility and has allowed us to remain faithful to our core mission of serving all New Yorkers without regard to insurance or immigration status. However, the unrelenting financial pressure we are experiencing represents a grave threat to our mission and to our long-term ability to maintain sufficient service capacity to meet the needs of our patients across the City. And, as a result, more tough decisions surely lie ahead.

Opportunities

One way we are meeting the challenge of doing more with less is by achieving greater efficiency through our continued redesign of our operations using Breakthrough, our employee-driven process improvement approach. The implementation of Breakthrough uses frontline staff members to help determine operational changes that allow us to work better and smarter to accomplish our goals. Since launching Breakthrough in 2007, our team-led rapid improvement events have achieved $377 million in financial benefits – nearly $349 in new revenues and $28.5 million in cost savings. There are 19 sites that have active Breakthrough teams working to make improvements in 71 operational areas. The vast majority of savings have come from five broad areas: inpatient services, Emergency Departments, ambulatory care, behavioral health and peri-operative services.

For example, Harlem Hospital was able to increase surgical capacity by approximately 14% by improving the pre-admission testing process, creating a standardized process for scheduling operating room time and increasing the number on-time starts.

At Bellevue, surgical services have been made much more efficient, reliable and patient-friendly by standardizing the surgical scheduling process and improving communication with patients. As a result, Bellevue has gone from having an average of 15% of its scheduled surgeries cancelled because of incomplete pre-procedure testing, to now having virtually none cancelled.

In another example, Metropolitan’s nursing department successfully used Breakthrough to decrease the rate of catheter-associated urinary tract infections by 60% in its medical-surgical inpatient units. Even as we struggle to make our system more efficient and to manage the formidable financial challenges we face, we continue to offer essential and high quality primary and preventive care services, with an emphasis on the early detection of disease and the effective management of chronic diseases such as asthma, diabetes, and hypertension which are so prevalent in the communities we serve.

We are also continuing to transform how we deliver care so that is better coordinated and managed. In January of this year, the federal Centers for Medicare and Medicaid Services designated HHC as an Accountable Care Organization in the Medicare Shared Savings Program with a focus on improving the health of Medicare beneficiaries through coordinated, high quality care delivered at reduced costs.

HHC’s investments and demonstrated ability in care coordination and care management also have resulted in our designation as a Health Home here in Manhattan and in three other boroughs. This means we have responsibility for managing the care of Medicaid patients with very complex medical conditions, including serious psychiatric illness and chemical dependency. We are the only organization to be given this responsibility by the State in more than one borough of the City.

As I have reported previously, all of HHC’s primary care sites have received formal certification as Patient-Centered Medical Homes. Now, all of these sites are in the process of being re-certified under more stringent standards, and we expect all to be recertified within the next three months. Already, ten HHC facilities – including Harlem Hospital, Metropolitan Hospital, and Gouverneur – have been recertified for another three years as Patient Centered Medical Homes at Level III, the highest level of certification.

HHC’s health plan, MetroPlus, will play a key part in the success of all of these activities aimed at delivering better care, helping our patients become healthier, and at the same time reducing costs. MetroPlus continues to be the highest rated plan in the City based on quality measures and customer satisfaction.

The investments we are making in information technology will have a significant impact on our success in these areas, as well. HHC has purchased a new electronic medical record system that will be phased in over the next five years. Our new system will enable our providers to share information more easily to better coordinate care, as well as give patients ready access to their health information, facilitating their ability to partner with their caregivers to improve their own health status. By meeting certain objectives for using certified electronic medical record technology to improve patient care, HHC has qualified to receive from the federal government roughly $122 million which will be used to offset the cost of our new electronic medical record.

Additionally, we are completing installation of a new billing and appointment scheduling system. The new scheduling system will be more patient friendly and will enable us to ultimately consolidate multiple call centers. As the Bloomberg administration draws to a close, I would like to thank the Mayor for the support he has shown for public health in New York City and for our system in particular, over the last 12 years. We have prepared extensive transition materials for the incoming administration, and we are beginning briefings next week. Based upon his public statements during the campaign, Mayor-elect de Blasio certainly understands the critical importance of the public hospital system, and we anticipate that he will continue the same strong support for its mission during these challenging times.

As we work to make our system more efficient, and manage our ongoing financial challenges, we continue to be responsive to the needs of our communities, and especially to the uninsured. In Manhattan, HHC provides 78% of all hospital-based outpatient visits and 40% of all inpatient stays provided to uninsured residents.

Our Work in Manhattan

Let me now briefly report on some of our most notable accomplishments in Manhattan.

Of course, among Bellevue’s and Coler’s biggest accomplishments this past fiscal year were their staffs’ capable and compassionate responses to Hurricane Sandy. At both facilities, staff ensured that patients received appropriate care during and after evacuations, and at Coler, staff diligently cared for the hundreds of residents who remained on the campus while the facility operated on generator power and portable heat. At Metropolitan Hospital, staff ably managed to meet the needs of a large influx of patients from Bellevue during that hospital’s protracted closure.

I cannot emphasize enough how remarkably HHC staff performed and responded to the challenges presented during and after Hurricane Sandy.

Now, let me move on to some other recent accomplishments by HHC’s Manhattan facilities.

Bellevue Received the American Heart Association’s Gold Plus Award, which recognized the hospital’s high quality of care for patients with heart disease. Bellevue also received recognition this year from the AARP as one of the “Top Hospitals for Safety”.

Just over a month ago, Bellevue opened a new, 15-bed inpatient psychiatric unit for adolescents that better enables the hospital to address the growing need for inpatient mental health services for children and adolescents. Bellevue had operated 30 child and adolescent inpatient psychiatry beds, and this expansion brings the total number of those inpatient beds to 45.

Earlier this year, Gouverneur Diagnostic and Treatment Center was the first HHC facility to be recertified by the National Committee for Quality Assurance as a Level 3 Patient Centered Medical Home. Its application received a perfect score on all services and programs required to be reviewed.

Gouverneur’s $250 million major modernization project is proceeding and is expected to be completed during the first half of 2014. The project includes renovation of its original 330,000 square foot building and construction of an additional 110,000 square feet. The project's scope of work includes replacement of aging infrastructure systems and addresses programmatic design deficiencies. The skilled nursing facility’s bed complement will be increased from 210 to 295, but most importantly the modernization project involved a total redesign of the facility to be more home-like and resident centered.

Gouverneur’s Skilled Nursing Facility was also selected to participate in a three-year pilot program to lower healthcare costs through a bundled payment model. The pilot program focuses on effective provider collaboration across the continuum of care and seeks to speed residents’ recovery as well as reduce hospital admissions and readmissions.

Metropolitan was designated as leader in LGBT Healthcare Equality as reported in the 2013 Healthcare Equity Index Report. The index is based upon a national survey conducted by the Human Rights Campaign Foundation, and it assesses a health care organization’s ability to meet the needs of the LGBT community in four specific categories: patient non-discrimination, equal visitation, employment non-discrimination and training in LGBT patient-centered care. Metropolitan met all four criteria.

This past year, all HHC hospitals focused on reducing unnecessary readmissions by patients with chronic heart disease. Metropolitan’s work has been among the best in our system, and it has successfully reduced those readmissions by more than half.

Harlem Hospital completed construction of its new six-story Mural Pavilion earlier this year. Clinical services now located in this space include operating rooms and critical care units, women’s imaging, surgery clinics, and bariatric services. The new Adult and Pediatric Emergency Departments are on track to open in January 2014 and will consist of single patient rooms, asthma and observation areas, and a trauma suite and radiological area configured to support Harlem’s Level I Trauma Center. A new chronic outpatient dialysis unit, outfitted with state of the art equipment and chairs, will expand the unit’s capacity to 25 chairs. The hospital’s unique collection of WPA murals have been restored and reinstalled in a specially designed gallery located in the atrium lobby of the pavilion.

Harlem Hospital is also one of two HHC pilot sites, Lincoln Hospital is the other, for a new initiative to give New Yorkers greater access to farmers markets’ produce and increase healthy eating. The Fruit and Vegetable Prescription Program enables patients at risk of obesity to receive Health Bucks, which are coupons from the Human Resources Administration and the New York City Health Department, that can be redeemed for fruit and vegetables at all New York City Farmers Markets.

Our Renaissance Diagnostic and Treatment Center sites have expanded hours of operation to 5 evenings per week and on the first and third Saturday of the month, and patient response has been very positive.

Renaissance has also been engaged its Breakthrough improvement work to improve access and patient satisfaction in adult primary care services. This work includes collaborative efforts with our unions and Community Advisory Boards to create a more patient-centered focus at these facilities, and it is yielding positive results. At Renaissance, the patient satisfaction survey scores related to access to outpatient services is now one of the highest among HHC facilities.

One of the Renaissance sites, the Syndenham Pharmacy, is undergoing a capital project to upgrade its heating and cooling system to enhance the comfort of its patients and staff. This project is expected to be completed by summer 2014.

Earlier this year, US News &World Report listed Coler-Goldwater Specialty Hospital and Nursing Facility as one of nation’s best nursing homes with the highest CMS rating of five stars. This national recognition is a well-deserved testimony to the Coler-Goldwater staffs’ professionalism, compassion and dedication to the highest quality of patient and resident care.

This past year Coler-Goldwater also implemented the innovative Music and Memory Program, designed for nursing home residents with dementia or cognitive deficits who benefit from a form of Music Therapy. This evidence-based program, that involves providing residents’ with customized play lists via iPods in a structured, supportive process, has been found to often diminish inappropriate behaviors, reduce the need for certain medications, improve mood, and increase activity participation. Nursing staff have reported that there have been improvements in observed behaviors in 71% of the residents who participate in the program.

Coler-Goldwater continues its active participation in the New York State coalition convened to train staff on evidence-based assessment, management and prevention of pressure ulcers. As a result, hospital-acquired pressure ulcer rates for Coler-Goldwater are less than one percent, well below the national average rates of 4.7% for nursing facilities and 3.8% for long-term acute care hospitals.

On November 24th and 25th, 228 patients were successfully relocated from the Goldwater campus to the new Henry J. Carter Specialty Hospital and Nursing Facility in Harlem. This new HHC facility features a 164 bed skilled nursing facility and a 201 bed long-term care hospital.

The state-of-the-art, 400,000 square-foot facility was built at a cost of $295 million and is named after “Hank” Carter, founder of Wheelchair Charities, Inc. in recognition of his 40 years of support to New Yorkers with disabilities and the more than $25 million in philanthropic support the organization has provided to HHC and the residents of Coler-Goldwater. The most recent gifts were specially equipped vans to be used by the new facility’s patients and residents. Our Coler Nursing Facility remains in operation on Roosevelt Island serving more than 800 residents.

Conclusion

I am proud of the work that our dedicated HHC staff performs every day here in Manhattan and across our city to provide accessible, high-quality healthcare to our patients. I can assure you that the leaders across our organization, as well as our Board of Directors, are advocating at every level of government to secure the resources necessary so that HHC can continue to effectively meet the needs of our vulnerable patients and communities. We appreciate the strong advocacy support that we receive from our partners in labor, our community advisory boards and auxiliaries, and many community-based organizations that care about our mission. Our strong connection to, and support from, the communities we serve is one of our most important assets.

Thank you for your attention and your attendance. I will now turn the program over to Mr. Russo. I look forward to hearing your comments.