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 Brooklyn annual public meeting, the last of five borough-specific meetings we convene each year. This public meeting has been delayed substantially as we worked to repair the damage caused by Hurricane Sandy. 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 Brooklyn senior executives. Our host this evening is Arthur Wagner, the Senior Vice President of the South Brooklyn Network and Executive Director of Coney Island Hospital. Also in attendance is George Proctor, the Senior Vice President of the North and Central Brooklyn Network and the Executive Director of Woodhull Hospital. Ernest Baptiste, who has been serving as Executive Director of Kings County Hospital Center since August, is also here with us, as well as Michael Tartaglia, who was appointed as the new Executive Director of Susan Smith McKinney last fall.
I thank all four of them for the excellent work they do every day as leaders helping us to render the best possible care to the residents of Brooklyn.
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 Community Advisory Board members from Coney Island Hospital, King’s County Hospital, Woodhull Hospital, Cumberland Diagnostic and Treatment Center, East New York Diagnostic and Treatment Center, and Susan Smith McKinney Nursing and Rehabilitation Center, all of whom advocate on behalf of our public system and help keep us grounded and responsive to the needs of our patients and communities.
Let me begin by speaking briefly about Hurricane Sandy and its dramatic and wide-ranging effects on HHC. First, let me say that in the face of this unprecedented event, it was the diligent planning, hard work, bravery and selfless dedication of thousands of HHC staff that protected our patients from harm, and helped relieve their discomfort and anxiety during the storm and in its immediate aftermath. Many staff, often despite their own concerns for family and home, worked tirelessly over multiple shifts with a determined focus on ensuring the wellbeing of our patients.
Before the storm, HHC Central Office Emergency Management and local facility leadership activated Emergency Response Plans; emergency generators were tested and fully fueled; and extra supplies and food were secured. Disaster staffing patterns were set in motion, and preparations were made for staff to sleep over at their facilities. Eight Special Medical Needs Shelters were opened, and staffed round the clock with the help of HHC personnel who worked extended shifts caring for some of the City’s most fragile residents, who were displaced by the storm.
Many of our employees suffered storm-related effects, some experienced personal hardships and others found it difficult to get to work because of transportation disruptions and fuel shortages. Despite these challenges, HHC’s facilities here in Brooklyn did superb work during and after the storm.
As you know, both Coney Island Hospital and Bellevue Hospital were severely damaged by the extraordinary storm surge and both had to be evacuated. I was in the emergency command center here at Coney Island Hospital on the night of the storm and witnessed the exemplary performance of the hospital staff who reassured and protected patients as the rising waters flooded the basement and eventually washed through the first floor of the hospital.
Hospital evacuations present a significant risk to patients, even when performed under the most optimal conditions and this is why a decision to evacuate before a forecasted storm is not made lightly.
It is a testament to the skill and commitment of our staff here at Coney Island and at Bellevue that nearly 1,000 patients, including many critically ill patients, were evacuated safely. All of these patients were transferred without incident into the hands of caregivers at sister HHC facilities, and to non-HHC hospitals. Transfer information was made available to families as quickly as possible.
Both Coney Island and Bellevue worked quickly to restore, first, outpatient services and then limited emergency department services. Coney began to accept inpatients in the middle of January and has now restored most of its services; however, it has not yet restored its obstetrical services and its emergency department capacity remains limited as the rebuilding of its heavily damaged emergency department is completed. We anticipate that full services will be restored by the end of this month. Bellevue Hospital has now fully re-opened and has resumed its Level 1 Trauma Center status.
Additionally, the Ida G. Israel Community Health Center, an offsite ambulatory clinic of Coney Island Hospital, was irreparably damaged by flooding and was irrecoverable. Therefore, Coney Island leadership has identified another community based site which is less vulnerable to future storms so that we can continue to provide much needed ambulatory care services to the community and patients who depended upon the Ida G. Israel Center.
The Coler campus of the Coler-Goldwater Specialty Hospital and Nursing Facility, one of our long-term care facilities which serve some of the City’s physically fragile and chronically disabled individuals, lost power and heat after the storm. This made it necessary to transfer 104 medically fragile patients to Goldwater. More than 500 patients remained at Coler, kept safe by Coler staff, until power and heat were restored. Our work to permanently repair the damaged electrical systems at this essential long-term care facility continues and should be completed by the end of this month.
Finally, some of our Central Office locations sustained damage from the storm. More than 1,200 staff members working in key areas such as the Finance Department, Home Care, the IT Department, and MetroPlus Health Plan have been displaced from 160 Water Street in lower Manhattan. Despite being deployed among several sites across the City, these resilient and dedicated employees have continued to carry out their essential operational responsibilities. Our staff began moving back into the repaired 160 Water Street building earlier today.
There were so many HHC superstars during the storm. It would take the entire evening to talk about all of them, so I will highlight the efforts of only a few.
After Hurricane Sandy knocked out electrical power here at Coney Island Hospital, and flooded the basement and first floor, staff did a remarkable job calming and safeguarding the more than 200 patients in house. Daniel Collins, Director of Facility Management, and his staff, deserve special praise for quickly powering down the emergency generator before it was shorted out by the rising flood waters. Only because they did so was it possible for them to restart the generator when the flood waters receded, restoring sufficient power to light the facility and energize the elevators for the subsequent evacuation of patients. The loss of all power posed a particular danger to the more than 30 patients in the hospital who were on ventilators. The nurses, respiratory therapists and other clinical staff responsible for those patients did a superb job ensuring that all ventilators continued to function properly on backup battery power during the four hours when the hospital had no power and then in safely evacuating these highly vulnerable patients.
When Kings County Hospital Center was asked to assist with providing mental health services for evacuees at the Park Slope Armory Shelter, Dr. Elizabeth Owen, Dr. Sander Koyfman, and Dr. Akinola Adebisi stepped up to provide the critical support. Dr. Adebisi was at the Armory when 400 patients from three private nursing and adult home facilities arrived at the shelter. Patients from one nursing home arrived with garbage bags full of jumbled medications, and Dr. Adebisi patiently sorted through all of them to match medications to the appropriate patients. Working around the clock for a week, Dr. Owen and Dr. Koyfman provided psychiatric care not only to the evacuees but also to staff members, many of whom were suffered personal trauma related to the storm.
Although we have completed the first phase of our recovery from the storm by reopening our most heavily damaged facilities, there is still much work to be done to complete permanent repairs and to protect our facilities against any future storms of this magnitude. We are grateful that the City has appropriated $710 million as an advance against anticipated FEMA reimbursements for repair, restoration and risk mitigation efforts related to HHC facilities.
We remain very concerned, however, about the more than $200 million dollars in operating costs incurred during the period when our Coney Island and Bellevue facilities were fully or partially closed, as these costs may not be FEMA-reimbursable. If not addressed, this loss will severely destabilize our finances going into next fiscal year. We remain hopeful that a portion of the several billion dollars appropriated by Congress in storm-related Community Development Block Grant funds can be tapped to cover the loss.
HHC has faced adversity before, and we have come out of it stronger. We expect the same to be true in this instance, though the physical and financial damage to our facilities is significant, and will strain our budget and make it even more challenging to implement the strategic initiatives planned for the coming year. Nonetheless, I have full confidence in our ability to rebuild and in the resilience of the incredible staff, both at our facilities and in our central offices, who work tirelessly to ensure that we sustain our mission in serving all of the patients who need us.
Let me now focus on the very significant financial challenges HHC faced before the storm -- challenges that will continue to intensify.
At the City level, as a result of a forecasted $2.5 billion budget gap for the fiscal year beginning July 1, 2013, City agencies have been required to submit spending reduction proposals. For HHC, this means a 5.4% reduction to our baseline City funding, or a $4 million cut. This will increase to an 8% reduction, or a $5.1 million cut in 2014 and beyond.
We also face diminishing state and federal funding. Cuts mandated by the Budget Control Act of 2011 took effect in March and, unless changed by Congress in the future, will result in across the board cuts totaling $1.2 trillion over ten years. Medicare provider payments will be cut 2% and we estimate that this and other related cuts will reduce HHC’s revenue by $20 million in the first year. On top of this, still more Medicare and Medicaid cuts have been proposed by Congress and the President which could reduce funding to HHC by tens of millions more per year as part of the debate over federal spending.
Beyond these looming reimbursement cuts, we are increasingly in an environment where we will be expected to deliver better care, with better patient outcomes at lower costs. Healthcare providers throughout the country are also dealing with these same expectations; however the challenges for HHC are greater because we provide care for so many uninsured patients, yet continue to receive less and less funding for that work.
And under the federal health reform law, upheld by the Supreme Court in June, beginning in 2014 the federal government will make significant reductions to supplemental Medicaid and Medicare funding that supports public hospitals and other safety net institutions. Ultimately, these cuts could reduce HHC’s federal funding by more than $325 million annually. There is very little prospect of Congress re-visiting the wisdom of these looming, devastating cuts.
As a result of these factors and others, we continue to grapple with a daunting budget gap, and we are in the third year of a four-year cost containment and restructuring plan projected to yield $600 million in new revenue and cost savings. We remain on target with this plan, and we expect to have closed the budget gap by roughly $589 million by the end of this fiscal year. Our workforce now has 3,600 fewer full-time employees than three years ago. Most of this workforce reduction has not involved direct patient care positions and, to the credit of our dedicated employees, we have maintained nearly the same service capacity across all care settings.
It is important that our stakeholders understand what we are up against and why we have resorted to measures such as workforce reductions through attrition and targeted layoffs, as well as the consolidation or outsourcing of certain services to lower our expenses. HHC’s senior leadership team is fully committed to keeping our financial plan on track while continuing to provide high quality, safe care to our patients. But this does require a fundamental re-thinking about how we maintain service capacity with fewer resources. For example, one of our cost-containment initiatives is a new contract for dialysis services that will enable us to increase our dialysis capacity by 35% over the next three years while saving an estimated $100 million over a nine-year contract period. We will continue to guarantee access to dialysis services for all patients without regard to insurance or immigration status, and no HHC staff member will lose employment as a result of this contract.
Let me stress that we are looking at every conceivable way to close our budget gap without adversely affecting our capacity to serve our communities, without negatively affecting access to care and without diminishing the stellar gains in safety and quality that we have made. That said, given the additional reductions in federal funding starting later this year, it will be considerably harder to achieve these aims.
Another way we are addressing these financial challenges is to achieve greater efficiency through redesign of our operations using Breakthrough, our employee-driven process improvement approach. With Breakthrough, we use the experience, skill, and creativity of staff at all levels to help improve services, take out waste, and reduce cost. Since its launch in 2007, more than 7,500 employees and affiliate staff have been involved in Breakthrough activities, leading to roughly $284 million in new revenue and cost savings.
Here are some examples of the Breakthrough work in our Brooklyn facilities:
At Kings County, the Patient Care Committee of the Community Advisory Board recommended that a Breakthrough team work on addressing excessive waiting time in the outpatient pharmacy. The team, which included two members of the CAB, came up with operational improvements that reduced waiting time for filling new prescriptions in the outpatient pharmacy by 50%.
Last year Coney Island, an early adaptor of Breakthrough, celebrated the completion of 100 Breakthrough rapid improvement events that have had a significant positive impact on patient care, satisfaction, safety, and cost. Coney Island’s behavioral health unit used Breakthrough events to improve patient satisfaction scores significantly.
Woodhull Hospital used Breakthrough teamwork to reduce the average length of stay in its inpatient psychiatric units by a dramatic 42%, effectively freeing up beds sooner so that more patients needing psychiatric admission could be accommodated.
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. HHC facilities provide nearly 220,000 hospital inpatient stays, more than 1 million ED visits, and more than 5 million outpatient visits annually. In Brooklyn, HHC provides 70% of all hospital-based clinic visits and 40% of all inpatient stays made by uninsured residents. And we continue to offer the communities we serve a full range of primary and preventive care services, emphasizing early detection of disease and effective management of chronic diseases such as asthma, diabetes, and hypertension.
HHC has moved forward in a number of areas that will help us transform care in a positive way for our patients. This past year, we have met new federal standards for implementing effective health information technology, including electronic medical records. As a result, we are slated to receive $82 million in federal funding to support further development of our health information technology. Payments began in June 2012 and we have already received more than $57 million of these funds.
Last year I spoke about our successful efforts to convert HHC’s primary care clinics into Patient Centered Medical Homes. Such medical homes match each patient with a dedicated team of providers who offer coordinated, comprehensive care. Medical Homes improve continuity of care for patients and earn additional reimbursement. HHC is projected to receive $21 million in available state funding to support the continued strengthening of the patient-centered medical homes model.
In addition to our work in developing patient-centered medical homes, HHC and our health plan, MetroPlus, received New York State designation as a Health Home for Queens, Manhattan, Brooklyn and the Bronx. Health Homes are paid to be responsible for assuring that people with mental illness and multiple chronic conditions – who too often wind up in emergency department - have better access to primary care as well as improved coordination and care management. Assuming responsibility as a Health Home is a part of our effort to strengthen services for vulnerable populations, improve outcomes, decrease unnecessary Emergency Department visits, and decrease unnecessary hospital admissions.
HHC has also been approved to participate in the Medicare Shared Savings Program as an Accountable Care Organization (ACO). This initiative creates a new model of service delivery to offer Medicare beneficiaries higher quality care while reducing costs through increased efficiency and integration of services. To receive incentive payments, the HHC ACO will have to measurably improve the health status of patients through evidence-based clinical practices, and lower spending for the Medicare program by reducing unnecessary hospitalizations, re-admissions, and Emergency Department visits for designated Medicare patients.
Robust primary care is the foundation of health reform, and as a step toward meeting the need for more primary care doctors in the future, HHC and St. George’s Medical College have collaborated on the City Doctor’s Scholarship program. Over the next five years, we will offer $11 million in tuition-based scholarships to New York City residents who attend St. George’s Medical College and commit to practice primary care medicine at an HHC hospital. Eleven scholarships were awarded this past year, and more scholarships will be awarded this coming year.
Our Work in Brooklyn
Here in Brooklyn, our public hospitals continue to exceed national benchmarks on many important publicly reported measures of quality and patient safety. Both Kings County and Coney Island had successful Joint Commission surveys in last year and both received full accreditation.
At Kings County Hospital, the behavioral health Intensive Crisis Stabilization & Treatment Program was recently recognized by the American Hospital Association for clinical excellence.
Also at Kings County, The Kings Against Violence Initiative (KAVI) program, aimed at violence prevention and intervention in the community, received funding from the Mayor’s Office and the New York City Department of Health and Mental Hygiene. The school-based component of the program at Wingate High School is in place and the hospital component is also now under way.
East New York Diagnostic and Treatment Center recently developed a Comprehensive Adolescent Pregnancy Prevention Program. Funded by grants from the State Health Department, the program is a partnership with the local YWCA, Intermediate School 292 and “Youth at Risk,” a citywide non-profit organization. The partnership is working closely to address issues focused on serving adolescents and families in East New York & Brownsville.
Woodhull Medical Center was one of two HHC facilities that were awarded a 5-year Regional Asthma Grant from the New York State Department of Health, aimed at reducing the burden of asthma in Brooklyn communities. The program focuses on increasing asthma control among children and seniors.
Woodhull also received HEAL 21 capital improvement funding from New York State to increase access to high demand outpatient care. Funding will be used to build a Pediatric Dental Practice and increase capacity in both Adult Dental services and Ophthalmology services.
Cumberland Diagnostic and Treatment Center recently began an innovative pilot project to use text messaging for appointment reminders for adolescent patients who have agreed to receive HPV vaccinations. If successful, the pilot will be expanded to other services.
Coney Island Hospital is participating in a pilot project in conjunction with HHC’s simulation and advanced learning center, to test the effectiveness of certain verbal de-escalation techniques that are designed for the behavioral health environment.
One of Coney Island’s nurse leaders, Donna Leno-Gordon, has been a driving force behind the development of HHC’s system-wide palliative care program, serving as the Chair of HHC’s Palliative Care Council. This past year she was a recipient of The Alfred P. Sloan Public Service Award. The Sloan award, given annually to outstanding public servants by the Fund for the City of New York, is highly competitive and its award to Ms. Leno-Gordon reflects on the excellent palliative care work being done here.
I appreciate and am proud, especially after Hurricane Sandy, of the work that our dedicated HHC staff performs every day here in Brooklyn 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 for HHC to 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 the 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 our moderator, Mr. Russo. I look forward to hearing your comments.