ALAN D. AVILES
HHC PRESIDENT AND CHIEF EXECUTIVE
REPORT TO THE BOARD OF DIRECTORS
NOVEMBER 20, 2008

HHC has collaborated with the New York Department of Health and Mental Hygiene (DOHMH) to develop guidelines and standardized tools for the treatment of hypertension for dissemination to HHC healthcare providers throughout the city. Hypertension, or high blood pressure, affects roughly 25% of all adult New Yorkers. Since it often has no recognizable symptoms, it is often called a “silent killer,” and can lead to cardiac disease, stroke and other dangerous health conditions. By controlling hypertension in our patients, we can have a very positive impact on their health status and lower their risk of premature death.

HHC's Office of Healthcare Improvement, together with the NYC Department of Health and Mental Hygiene, held a kick-off meeting for this initiative on November 7, 2008 at Metropolitan Hospital. Standardized hypertension guidelines, medication algorithm and pharmacy formulary, together with a Pocket Guide, that have been developed by HHC and DOHMH, were shared with more than the 175 clinicians, nurses, pharmacists, health educators and other staff from across HHC. A video on best clinical practices for the accurate measurement of blood pressure, also developed by the HHC/DOHMH team, was previewed at the meeting and will be distributed to all facilities by the end of this calendar year. Other topics discussed at the all-day event were: overview of hypertension in NYC; hypertension performance indicators reporting; self-management support; HHC facility-based hypertension initiatives; nutrition and medication adherence training; and the effect of home blood pressure monitoring, as well as pharmacist intervention, on hypertension outcomes.

The standardized initiative tools and components will be rolled out to all HHC facilities in January 2009, ultimately involving hundreds of providers across our adult primary care settings. A patient registry - similar to our diabetes registry -- has been developed to track all patients diagnosed with hypertension. By the second quarter of next year, we will begin producing quarterly reports of the number of HHC patients who are known to have hypertension and the percentage of those whose hypertension is under control.

Sometime next year, we will look to share our system-wide performance on this initiative on our public website, as we have with our work on the more effective management of asthma and diabetes. Special thanks go to Health Commissioner Tom Frieden for his leadership as Chair of the Board's Quality Assurance Committee in championing this important initiative.

We have begun to implement a major new Patient Safety initiative -- TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). The program is a toolkit of team building methods, developed by the Department of Defense and the Agency for Healthcare Research and Quality, that have been proven to improve team performance and patient safety. As part of the nationwide introduction of TeamSTEPPS, HHC was selected as one of the first large hospital systems to participate in initial training. To date, 12 HHC staff have participated in the TeamSTEPPS Master Trainer program and 150 HHC clinical and administrative leaders were introduced to concepts and tools of the program at a Patient Safety Forum in July. The TeamSTEPPS Guide to Action brochure is included in your packet today.

In late October, 55 members of the Comprehensive Psychiatric Emergency Program (CPEP) clinical and administrative team at Kings County Hospital Center received introductory TeamSTEPPS training. Special emphasis was placed on the importance of strong communication strategies, leading to the team development of what is called a "shared mental model" in clinical settings -- a common understanding of patient situation that is continually updated and shared by all members of the treatment team. The training was very well received by the CPEP staff. HHC's Master Trainer faculty will return to Kings County within the next month or so to debrief participants on implementation and the lessons they have learned.

In mid November, TeamSTEPPS training was also provided to 18 members of the Kings County Hospital Center Peri-operative Team. For this setting, the TeamSTEPPS curriculum was customized to focus on coordinated team actions, more effective communication exchanges, and achieving a shared mental model in a peri-operative setting.

In addition to the training at Kings County, introductory TeamSTEPPS training was provided at Coney Island Hospital in June, and we will soon launch TeamSTEPPS at Bellevue Hospital Center and other sites across the system. Our goal is to spread TeamSTEPPS across the system over the next two years.

In August, at the Governor's request, the State legislature enacted mid-year budget cuts to the Medicaid program. These cuts reduced HHC's Medicaid reimbursement by nearly $26 million dollars in FY2009 and $31 million dollars in FY2010. Last week, in light of the worsening economic outlook, Governor Paterson proposed an additional $1.8 billion in health care cuts to hospitals, nursing homes and home care providers as part of a plan to save $5.2 billion in the current and subsequent state fiscal year. The projected impact of the Governor's proposed health care cuts on HHC is $168 million - $46.4 million in state fiscal year 2008-2009 and $121.8 million in state fiscal year 2009-2010. Although the State Legislature was convened for a special session this week, it took no action on the Governor's proposed cuts. It now appears unlikely that there will be further legislative action on the budget until after the Governor releases his proposed budget actions for state fiscal year 2009-2010. It is expected that the Executive Budget, to be released on December 16th, will include additional deep cuts to address the projected deficit for the balance of this fiscal year ($1.5 billion) as well as for the next fiscal year ($12.5 billion). As you know, Medicaid reimbursement is the major source of funding for HHC's hospitals, health centers and nursing homes.

HHC has also received news from the City that projected pension costs will significantly impact HHC's financial plan. As I mentioned last month, HHC's employer contributions into pension funds is affected by the current economic crisis, because HHC pays the difference between what the pension funds assets earn in the market and the actuarial expectation of the cost to provide defined benefits to future pensioners. HHC pension expenses are now estimated to increase by $14 million in 2010, $36 million in 2011, $60 million in 2012 and $91 million by 2013. The City's recent wage settlement agreement with DC 37 will have another major impact to HHC's financial plan. This settlement is part of a pattern of recent agreements including Doctors Council and others. In total, the resulting projected annual payout for HHC, commencing in 2009, is $58.4 million, $76 million in 2010 and an additional $79 million in 2011.

To reduce expense and optimize revenue collections, we are expediting supply chain and other expense reduction initiatives, as we ramp up on-going efforts to ensure appropriate and complete charge capture across all service lines. However, in light of this ominous fiscal uncertainty, last week I sent a memorandum to our senior leadership directing that several actions be taken immediately to limit spending. There will be a hiring freeze on all positions, with exceptions only for critical needs, at the facilities that are over prescribed FTE ceilings; operating funds can no longer be used for capital-eligible projects; and additional internal controls will be implemented, as necessary, to eliminate expenditures on non-essential items. Although it is likely that we will need to take further action once the state budget situation is clarified to ensure that our expenses are in line with projected revenues, I am confident that by working strategically and collaboratively we can confront and successfully navigate the challenging times ahead.

At the Annual Public Meeting on Staten Island earlier this month and then in a series of articles in the Staten Island Advance, a great deal has been said about what HHC is doing and should be doing to address the healthcare needs of that borough. I wanted to clarify some of the facts.

There is no question but that the number of low-income and uninsured residents on Staten Island has increased in recent years, especially across the communities on Staten Island's north shore which have experienced an influx of new immigrants. Although some have argued that there is a need for a public hospital on Staten Island, I believe that the leadership of both hospitals would agree that current certified bed capacity is sufficient and that neither hospital is running at anything close to maximum occupancy.

It has been argued as well, that both hospitals on Staten Island are burdened with a disproportionate share of charity care because there is no public hospital to serve the uninsured. This has been proffered as a reason for the City and/or HHC to provide cash support to both hospitals to offset this charity care burden. In fact, although the number of low-income, uninsured patients has increased on Staten Island, the absolute number and the percentage of low-income residents lags far behind the other four boroughs. It is not accurate to say that either hospital in Staten Island faces a greater burden of charity care than voluntary hospitals in other boroughs, even though public hospitals exist in the other boroughs to serve uninsured patients. The most recent data available from the NYS State Department of Health shows that two-thirds of the voluntary hospitals in the other four boroughs have a charity care burden that is higher than Staten Island University Hospital. Even though Richmond University Medical Center serves a greater percentage of uninsured patients, there are 23 other voluntary hospitals in the other four boroughs that have a higher charity care burden.

Finally, there is a misconception that HHC has large sums of funding that could be re-allocated to Staten Island. In fact, HHC, like voluntary hospitals, derives virtually all of its income from third-party reimbursement; in the case of HHC, the revenues come principally from Medicaid and Medicare. HHC received roughly $100 million in direct city support this past year. Of course, the City picks up one-half the cost of most Medicaid reimbursement at HHC's hospitals, as it does at all the City's voluntary hospitals, including those on Staten Island. With those clarifications, let me briefly address the status of some of our current investments on Staten Island.

HHC has been engaged for almost three years in the Staten Island Health Access Program (SIHA), a temporary initiative to expand access to primary care services for low-income patients as more permanent solutions are put in place. As a result of the SIHA program, more than 2,000 individuals were enrolled in public health insurance programs and more than 6,600 uninsured individuals were registered to receive healthcare services from select community physicians. In preparation for the phasing out of the interim service delivery component of SIHA by December 31st, HHC has developed a multi-pronged transition plan, to ensure that SIHA participants connect with other resources to meet their healthcare needs.

One significant component of the SIHA transition plan is the launch of the mobile medical unit or Clinic-on-Wheels on Staten Island. It is very much like any small doctor's office, with two exam rooms, a waiting room and computer connectivity for electronic medical records within the South Brooklyn/Staten Island Network. Assuming that we receive final State approval within the next few weeks, it is our goal to have this program component up and running by January 1st. We anticipate that the Unit would accommodate up to 4,000 visits in the first year. The mobile medical unit will be in five locations where HHC has identified as high areas of need, with input from SIHA participants, community-based organizations and local clergy. HHC has also aligned the physical placement of the mobile medical unit with known places within these communities where people go for help.

In addition to the Clinic-on-Wheels, and in a matter of weeks, we will be adding family medicine capacity at our existing Mariner's Harbor and Stapleton child health clinics on Staten Island, so that adults can be served at these two sites. These two sites are on the North Shore of Staten Island and are very accessible by public transportation. SIHA participants will have the option of choosing to receive care at these sites as well.

Third, to further expand primary care capacity, we have made a significant investment in the Community Health Center of Richmond (CHCR), including funding renovations that will double its outpatient capacity. We are hopeful that those renovations will be completed by the end of December and this additional capacity also will be available to SIHA participants.

We are developing a brochure and other types of materials that will be distributed in the Staten Island neighborhoods and communities that we've served through the SIHA program, to inform residents about our transition plan and the additional primary care capacity that will soon be available. We will continue our relationship with the Staten Island JCC, the community-based organization that has been collaborating with us to enroll uninsured Staten Island residents in public health insurance programs. JCC will continue enrollment efforts for those eligible for public health insurance and they will help refer residents to the various HHC resources including the mobile medical unit, family practice health clinics and the CHCR for primary care services.

HHC has acquired two other locations on Staten Island from which we will provide primary and other ambulatory care. One site will be opened in 2010 and the other in 2011. We will continue to work with local elected officials and community representatives to find ways to address the growing needs on Staten Island.

• On December 4th, a ribbon-cutting ceremony will be held to celebrate the completion of Elmhurst Hospital Center's new 1,700 square-foot Computer Tomography (CT) Suite. This new suite, which features a new 64-slice CT scanner, located on the first floor of the main hospital, will support 15,000 procedures annually. The CT scanner can produce detailed images of any organ in a few seconds, can scan the whole body in half a minute and is the first technology to provide clear non-invasive images of the heart and its major vessels. With the new unit, patients in the Queens Network community will get state-of-the-art imaging services for improved diagnoses and treatment.

• On December 8th, Metropolitan Hospital will open its new Centers for Geriatric Care, with an inpatient unit on the 6th floor, and a 3,000 square-foot outpatient center on the first floor. The inpatient unit focuses special attention on prevention of falls and pressure ulcers, medication safety and discharge planning that attends to the special requirements of aging patients. The outpatient center is conve­niently located on the first floor of the hospital, with easy access to the onsite Pharmacy and Ambulette services. The Centers for Geriatric Care will use a multidisciplinary approach, and services will be provided by experts in diverse areas like Alzheimer's, Diabetes, Cardiology, Neurology, Oncology, Behavioral Health, Rehabilitation Medicine, and Palliative Care.

At the Greater New York Hospital Association Services Annual meeting yesterday, HHC received two awards of distinction. The first was the Innovation and Change Leadership Award in recognition of our significant system-wide achievements in the area of supply chain transformation. The second was the Environmental Achievement Award, which went to the North Bronx Health Network for implementing "green friendly" initiatives within the network's facilities. Congratulations to all the staff whose hard work has led to these outstanding achievements.

Dr. Linda Landesman, Assistant Vice President for HHC's Professional Services and Affiliations Division, has been elected Chair of the Executive Board of the American Public Health Association (APHA). APHA is the largest, oldest and most diverse organization of public health professionals in the world. APHA advocates for public health and the elimination of health disparities, works to ensure access to care, and protects funding for core public health services. Its members serve as advisors to important boards and committees at the national, state and local levels. Fifty-three state and regional public health associations are affiliated with APHA. Congratulations to Dr. Landesman and we wish her well during her leadership tenure at APHA.

Last week we learned that Dr. Judith Aberg, Director of HIV Services at Bellevue Hospital Center, is this year's recipient of the Dr. Linda Laubenstein Annual HIV Clinical Excellence Award. She will receive the award at a ceremony in Albany on December 2.

The award, established by the New York State Department of Health AIDS Institute, honors those physicians who provide the highest quality of clinical care for people with HIV/AIDS and are also distinguished by their compassion and their wholehearted involvement in the ongoing effort to achieve comprehensive care for persons with HIV/AIDS.

Dr. Aberg, an Associate Professor of Medicine at New York University, serves as the principal investigator for the NYU/Bellevue AIDS Clinical Trials Unit and is on the editorial boards of several clinical journals. Dr. Aberg is also co-chair of the HHC HIV Clinical Advisory Group. In 2006, she received the Constance B. Wofsy Womens' Health Investigator Award from the international Adult AIDS Clinical Trials Group, the largest HIV clinical trials organization in the world, in recognition of her efforts for the advancement of clinical care, research, and mentorship in the area of HIV and women.

We are privileged to have Dr. Aberg as a leader in our HIV treatment programs and congratulate her heartily for this prestigious recognition.

Lincoln Medical Center's new Ambulatory Care Pavilion; News 12 TV, 11/7/08

Jacobi Partners with DOH, BP on HIV Testing Initiative; Bronx Times Reporter, 11/7/08

Queens Hospital party a hit with premature babies, parents; The Queens Chronicle, 11/6/08

Gouverneur's $180 Million renewal is coming to Clinton & Madison; Grand Street News, 10/31/08

City Docs' Contract; Crain's Health Pulse, 10/31/08

Climbing to Success - HHC's nursing career ladder; Advance for Nurses, 10/30/08

Amid the Daily Chaos, a Certain Precision; Bellevue's ER, The New York Times, 10/28/08

Woodhull Health Satellite reopens; Fort Greene Clinton Hill Courier, 10/24/08

Dying for Some Decent Health Care - forum at Woodhull; Fort Greene Clinton Hill Courier, 10/24/08

Lincoln Hospital Auxiliary banquet raises funds for neglected and abused children; New York Amsterdam News, 10/23/08