Public Reports and Testimonies
Brooklyn Annual Public Meeting
Tuesday, November 26, 2013
Remarks by Alan D. Aviles
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 fourth of five borough-specific meetings we convene each year. A special thank you to the many HHC nurses in attendance today – it is always important for us to hear from you. 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 Brooklyn. Our host this evening is George Proctor, Senior Vice President of the North and Central Brooklyn Network and the Executive Director of Woodhull Hospital. Also in attendance is Arthur Wagner, the Senior Vice President of the South Brooklyn Network and Executive Director of Coney Island Hospital. Ernest Baptiste, Executive Director of Kings County Hospital Center, is also here with us, as well as Michael Tartaglia, the Executive Director of Susan Smith McKinney.
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 Woodhull, Kings County, Coney Island, East New York, and Cumberland 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.
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. As you all know, one of our Brooklyn Hospitals, Coney Island, was dramatically affected. Sandy left Coney Island in one of the most difficult scenarios possible for any acute care hospital: a loss of power, the first floor submerged, and major flood damage in basements and mechanical spaces. The hospital was forced to evacuate more than 220 patients, which it accomplished without any adverse outcome.
In addition to the flood damage to the emergency department and other services on the entire first floor, a majority of the facility’s critical systems were destroyed or damaged, including electrical transformers and switchgear; ventilation air handlers; and communication equipment. As a result, the hospital could not provide emergency and inpatient services for a protracted period and patients had to be diverted miles away to other hospitals. Additionally, Ida G. Israel, an offsite ambulatory health center of Coney Island Hospital, was completely destroyed by flooding.
As of today, most of Coney Island’s inpatient services are operational, while the emergency department and most other first floor areas have been restored. Electrical switchgear that was ruined in the basement has been replaced on a new elevated platform adjacent to the hospital. Imaging services are being provided in temporary trailers until permanent imaging locations are rebuilt. And to help minimize flood damage from future storms, the hospital has acquired temporary barrier systems that can be erected around the ED, main entrances, and the generator facility in advance of any future storm.
Services formerly available at Ida Israel are temporarily being provided at the hospital and through a mobile medical van located at West 30th Street and Mermaid Avenue. We are in the process of erecting a temporary pre-fabricated medical facility at West 19th Street near Surf Avenue on land owned by the NYC Department of Housing and Preservation. This site, which is less than a half-mile from the original Ida Israel location, will be elevated eight feet above the ground. The building will house all of the medical, dental and behavioral health services formerly provided at Ida Israel.
Coney Island Hospital still needs to complete the elevation of its critical systems well above the grade, and we hope to complete this work next year. Ideally, in the longer term, key services and infrastructure components that are on the first floor, including the medical and psychiatric emergency departments as well as imaging services, are best protected by building a new elevated structure in the adjacent parking lot. The building of such a new structure -- an expensive proposition -- is contingent upon the availability of capital funding. Across the rest of the public system, we have had to repair several severely damaged facilities beyond Coney, notably Bellevue Hospital and Coler Specialty Hospital and Nursing Facility. Additionally, we have been working to make those at-risk facilities more resilient to minimize the impact of any future severe storm.
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 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 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, last week the Mayor added $12.5 million to HHC’s baseline budget for fiscal year 2015 and beyond. This represents funding that the City Council restored to our budget this year to help fund our child health clinics, certain developmental disability services, as well as other operational expenses. Now that these funds have been base-lined, we are spared the annual uncertainty of whether we can persuade the City Council to restore them.
However, 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 this fiscal year on July 1st, HHC also had successfully met its workforce reduction target of 3700 full-time equivalent positions one full year ahead of schedule, which contributed to an annualized $600 million reduction to our budget gap.
Most of this 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 virtually the same service capacity across 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 efforts to consolidate targeted services, centralize procurement, improve revenue collection and maintain our lowered workforce headcount. These efforts, when fully implemented, aim to achieve savings of $390 million in FY2015, which begins next July.
HHC’s senior leadership team has been exploring every 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 be very challenging, given the reductions in federal funding that started this year.
And beginning next year, under the Affordable Care Act, 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, in light of the severity of our financial challenges, it is important that all stakeholders fully appreciate the forceful political advocacy required 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, make additional significant government support unlikely 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 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.
One way we are meeting the challenge of doing more with less is by achieving greater efficiency through the 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 its inception in 2007, we have accrued $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 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, Woodhull has recently focused on ambulatory care, and the number of patients seeing their assigned primary care doctor has increased from 90% to 97%. Today 74% of their ambulatory care appointments occur on time, up from 56%. This is not only important to improving patient satisfaction, but also critical for optimizing patient flow.
At Kings, the behavioral health outpatient department team has worked on decreasing wait time for first appointments in the outpatient department. When Breakthrough teams began their improvement work the wait time for a first appointment was a full six weeks, and thus far the wait time has been reduced to 13 days.
Coney Island used Breakthrough to redesign its Emergency Department admission process. The changes decreased the time for admitted patients to actually reach an inpatient bed from more than two and a half hours to an average of one hour and twenty minutes.
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 services to the communities that we serve. To promote wellness, we continue to offer robust primary and preventive care services, with an emphasis on the early detection of disease and the effective management of prevalent chronic diseases such as asthma, diabetes, and hypertension.
We are continuing to transform how we deliver care that is better coordinated and better 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 the Brooklyn 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 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 with the next three months. Already, ten HHC facilities -- including Coney Island, Woodhull, and Cumberland -- 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 managed care 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 health status. By meeting certain objectives for using certified electronic medical record technology to improve patient care, HHC has qualified to receive $122 million in federal dollars to help offset the cost of the new electronic medical record.
Additionally, we are completing installation of new billing and appointment scheduling systems. 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 expect to begin briefings soon. 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 Brooklyn, HHC provides 73% of all hospital-based clinic visits and 39% of all inpatient stays made by uninsured borough residents.
Our Work in Brooklyn
Turning specifically to our work in Brooklyn, let me first discuss the unstable healthcare landscape in Brooklyn.
Two major Brooklyn hospitals -- Long Island College Hospital and Interfaith Medical Center -- are currently struggling to stay open and several others are facing very difficult financial challenges. It is not unreasonable to say there is a looming healthcare crisis in Brooklyn.
We are particularly concerned about the impact that a closure of Interfaith Medical Center will have on the demand for emergency department and psychiatric services at Woodhull and Kings County Hospital, two services that already contend with very heavy demand. We already have begun the process of adding additional psychiatric beds at Kings County and we are expanding our psychiatric emergency services capacity at Woodhull.
We certainly have been in discussions with the New York State Department of Health about other contingency planning and we have always been prepared to be part of any thoughtful process for restructuring the delivery of services in central Brooklyn. However, as we have made plain to the State, for our facilities to accommodate otherwise unmet community need in the face of hospital closures, we will require both additional resources from the State and sufficient advance notice to expand our service capacity at Woodhull and Kings County.
Now, let me briefly report on some recent accomplishments by our HHC facilities in Brooklyn.
At Woodhull Hospital, we continue to operate our innovative Center for Integrated Health, which integrates primary care into the hospital’s psychiatry outpatient service, with the goal of providing more holistic care to psychiatric patients with other chronic disease. Over the last two years, more than 1,000 high-risk patients have been referred to the Center. And we are also starting to see examples of its effectiveness, as 55% of patients with diabetes who are now seen at the Center are in good control of their condition.
Woodhull also has collaborated with external partners to advance nursing education opportunities. They have partnered with Borough of Manhattan Community College to develop a Graduate Nursing Externship Program, with Lehman College to develop an on-site RN BSN degree and a Master’s degree program. Additionally, College of New Rochelle Nursing School will provide senior BSN students with a leadership practicum where Woodhull nursing directors serve as preceptors.
This year, Woodhull also implemented the Video Interaction Project in collaboration with NYU to reduce disparities in development, school readiness, and educational achievement for children living in poverty. Starting from birth, the project arranges to videotape playing or reading sessions between parent and child that are reviewed by child development specialists who identify and reinforce positive interactions.
Both Woodhull and Coney Island earned top performing hospital awards for excellence and superior clinical outcomes in women’s health. Woodhull received the Healthgrades 2013 Gynecologic Surgery Excellence Award and also ranked among the top 10% of best performing hospitals offering high quality gynecologic surgical care.
Coney Island Hospital received the Healthgrades 2013 Maternity Care Excellence Award, and it ranked among the top 10% of best performing hospitals for services to mothers during and after childbirth or for the care of their newborn babies.
Coney Island is nearing completion of a major modernization to its adult and pediatric services, including additional state of the art exam rooms and adult critical care trauma bays. During 2013, Coney also replaced all Main building windows and air conditioning units, at a cost of $11 million, significantly enhancing patient care and improving energy efficiency.
In implementing the Patient Centered Medical Home model, Coney Island has expanded evening and weekend hours for its outpatient services, including pharmacy, and the hospital has increased access to walk-in/same day appointments. Additionally, the hospital operates a new call center for scheduling appointments, accessible 24 hours a day, seven days a week, with operators who speak several languages.
In 2013, Kings County Hospital Center received the Science and Service award from the federal Substance Abuse and Mental Health Services Administration. The award recognizes improvement in patient outcomes using evidence-based practices, as well as innovative techniques to improve patient engagement and retention.
Kings County also received a Patient Safety Award from IPRO, the federally designated quality improvement organization, for excellent infection control practices based upon there being not a single Central Line Acquired Blood Stream Infection in its intensive care unit over a 24 month period.
In partnership with three community-based organizations, Kings County Hospital implemented a program known as CureViolence that brings trained violence interrupters and outreach workers into the emergency department to perform mediation services, to prevent retaliatory violence among friends and family of hospitalized gunshot victims. This innovative program is an evidence-based public health approach to violence prevention, funded by a grant from the Young Men’s Initiative of the Mayor’s Office.
In January 2013, our East New York Diagnostic and Treatment Center received a grant from the federal Health Resources and Services Administration for capital improvement of their School Based Health Centers. This allowed us to upgrade the physical environment of these critical school health services.
Another of our Brooklyn facilities, Cumberland Diagnostic and Treatment Center, was recently awarded Certification as a Diabetes Center by the National Council on Quality Assurance. The center also continued to make progress with its Text-To-Teens Program that allows the center to send reminder texts of a teen’s next scheduled appointment. Since Text-To-Teens was initiated, the HPV vaccine completion rate for teens who begin the three dose vaccination has improved from 41% to 77%.
Our long-term care facility in Brooklyn, the Dr. Susan Smith McKinney Nursing and Rehabilitation Center, has now been rated as a five star facility by the Centers for Medicare & Medicaid Services. Only 20% of facilities nationwide receive this prestigious designation.
I am proud 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 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.