LA Health Collaborative
South L.A. Health Care Developments
December 21, 2006
LA Health Collaborative
South L.A. Health Care Developments
December 21, 2006
Meeting Notes
I. Welcome, Introductions and Agenda Review
Yolanda Vera, Director of LA Health Action, welcomed everyone and reviewed the agenda. Participants introduced themselves, including their reasons for attending the meeting.
II. Presentation on South L.A. Health Care Disparities
Dr. Patrick Dowling, Chair of UCLA Department of Family Medicine, provided a presentation on health care disparities in South L.A. (Attachment A).
III. Dialogue on South L.A. Health Care Developments
A. LACDHS
Sharon Grigsby, Chief Network Officer of LACDHS, reported on KDMC and MetroCare. Given the CMS termination of KDMC's Medicare provider agreement on September 22, LACDHS was left with two options. The first was to close the hospital, which was not acceptable given the need for inpatient services in SPA 6. The second was to have another entity run KDMC, which had challenges including finding an entity to take it over and fulfilling any Maintenance of Effort requirement. LACDHS raised a third option to CMS of bringing KDMC under the wing of another LACDHS hospital (Harbor/UCLA Medical Center [HUMC]), with its clinical leadership assuming management responsibilities. CMS accepted this alternative. However, it generated serious concerns at Harbor about a negative impact on HUMC's standing and accreditation.
With legal consultation and assurances of protection for Harbor, the MetroCare plan was developed and approved by the Board. Based on the Board’s actions, CMS extended King’s certification to March 31, 2007. LACDHS held meetings twice a week with leadership from KDMC and HUMC to implement MetroCare. Under the plan, KDMC was simplified to a basic community hospital model and renamed Martin Luther King/Harbor Hospital (MLKHH). With the unanticipated loss of ACGME accreditation, Drew University's 250 residents departed from MLKHH on December 1. As a result, LACDHS' John Cochran sought bids for ER physicians to replace residents as well as doctors to admit and monitor patients; beds for county patients at nearby private hospitals; ambulance services; and transportation for patients and families from MLKHH to HUMC. Contracts were in place by December 1, which allowed MLKHH to maintain patient services. The contract ER physicians at MLKHH are seeing the same volume and moving patients to beds, with a decline in waiting times and a decrease in the percentage of patients who left without being seen.
Ms. Grigsby closed her remarks by saying that LACDHS has secured continuation of inpatient care at KDMC and plans to be back up to 114 beds by Fall 2007. LACDHS has received support from the unions and other groups during this transition, but more work remains to be done.
Questions were asked, with the following answers given:
· Regarding what will happen leading up to March and in March 2007, Ms. Grigsby replied that March 2007 represented an extension granted by CMS from the original timeline. LACDHS is having weekly Wednesday morning conference calls with State DHS Licensing and Certification program and CMS. They have established target dates for re-staffing and re-determination.
· Regarding what is the estimate of costs to implement MetroCare, given that the figures of $54 million and $94 million have appeared in various documents, Ms. Grigsby said that $54 million represented LACDHS' request to the State to share costs while $94 million is the worst-case scenario. With the largest cost being staffing, LACDHS obtained Board approval not to layoff or cascade staff; instead excess KDMC staff would be placed on the many staff vacancies throughout LACDHS. LACDHS will transition staff no longer needed at MLKHH in February. In addition, the $94 million includes the costs of IT and other transitions.
· Regarding the census in the ER before and after the transition, Ms. Grigsby said she did not have that information but would be glad to supply it for the group.
B. LACDMH
Dr. Roderick Shaner, Medical Director of LACDMH, spoke on the opportunities and challenges driven by the MetroCare plan. Opportunities exist due to the evolution of service designs to better meet the needs of diverse, urban communities. In the last two years, the passage of the Mental Health Services Act (MHSA), formerly known as Proposition 63, has brought new sources of funding to implement new programs, which makes LACDMH well poised develop innovative services. The MetroCare-related mental health care challenges faced include the loss to the community of hospital-based psychiatric emergency services formerly provided in the MetroCare area, coupled with the fact that MHSA (Prop. 63) resources are not easily adaptable to fill this particular need, as they are primarily designed for community-based treatment.
LACDMH's response is to work with LACDHS to coordinate inpatient and ER services to maximize effectiveness, identify existing resources and get patients to them as efficiently as possible, recognizing the available resources will continue to evolve. In the area of alternative crisis services, which MHSA (Prop. 63) can fund, LACDMH will further develop psychiatric urgent care centers to which patients are brought involuntarily, designating a LPS mechanism for detaining mental health patients while robust 24-hour services are being developed. Prop. 63's Full Service Partnerships (FSPs) provide wraparound care for the severely mentally ill, allocated throughout the county based upon identified community need. Psychiatric Mobile Response Teams (PMRTs), which respond to crises in the field, evaluate individuals and transport them to LPS facilities, are currently being used for crisis management at the ER. A state mechanism exists (with proper licensing, the required number of locks and other factors) to transfer LPS designation, which has allowed LACDMH to maintain beds. Jim Allen, Deputy Director, and Kathleen Daly, Regional Medical Director for Systems, Planning and Development, of LACDMH spoke about the expansion of family-focused services. At Augustus Hawkins Mental Health Center, services are being provided to both children and adults to prevent hospitalization and ER use. A similar approach is being used in LACDMH's Community Reintegration Demonstration Project, which provides services to severely mentally ill women released from Century Regional Detention Facility. The California Endowment provided funding for primary care services, and the Southside Coalition of Community Health Centers are participating.
Questions were asked, with the following answers given:
· Regarding the number of involuntary commitments and where each segment is going since the closure of the psychiatric ER, LACDMH's Curly Bonds answered that out of 350 individuals per month, 90% are committed involuntarily. Most people are coming through law enforcement. Patients are showing up at other facilities, while some are still going to MLKHH. The PMRTs are coming to provide services to these patients, who are being referred to urgent care or another location as appropriate.
· Regarding the number of FSP slots in SPA 6, Dr. Shaner answered that there are approximately 1,500, but these are rough numbers as some are through DMH-operated facilities and some are through contractors. It will likely take about 6 months to outreach to fill up the slots. The second wave of FSP allocations is being made.
· Regarding whether LACDMH is using neighboring clinics to do prevention, early intervention and outreach, Dr. Shaner replied that LACDMH is embarking on this effort to interface with primary care at some of its mental health centers, including August Hawkins, Compton, Coastal Asian and Long Beach Asian Mental Health Centers. Dr. Southard has indicated that LACDMH will develop a MHSA reimbursement stream for this purpose.
C. Drew University
Dr. James Kyle, Vice President of Strategic Planning of Drew University, stated that the school is committed to training physicians. The loss of residency programs created an unstable environment, but the university will come back later and reapply. The university is having multiple conversations with hospital systems. The displacement of faculty has been challenging. The current residents have funding through June 2007, and the university is working on future placements. The university is planning to reapply for ACGME accreditation in 2007/2008. The university’s medical students are accessing ambulatory care at other county facilities and UCLA. Regarding research, the university recently held a three-day strategic planning retreat, which included:
· Involving the private sector;
· Distributing training across the community;
· Constructing a new building which will include a virtual medical group and making associations with community clinics to increase access to primary and specialty care;
· Addressing facts such as in 2006 there are fewer hospital beds and physicians than in 1965 and with the number of hospitals closing medical care will not be adequate given community need; and
· Addressing other allied health professionals, such as PA students.
Drew University remains determined and focused on its future and vision, looking toward creative methods to transition.
Questions were asked, with the following answers given:
· Regarding the poor distribution of county resources, Dr. Dowling replied that the loss of training programs combined with the area’s HPSA designation compounds access issues. The training location for physicians is the best predictor of future practice sites.
· Regarding the top three things the public and community can do to ensure a thriving a medical school in South L.A., Dr. Kyle replied that several helpful items include planning money for the creation of a four-year medical school, getting cooperation from the private sector on placement and residency, collaborating with clinics, developing a faculty practice plan, scholarships, letting people know about career opportunities, and outreaching to the Latino community. The university is working with the UC System to create a School of Nursing and seeking foundation support for the planning phase.
· Regarding the need to plan for community education on the loss of residency programs, Dr. Kyle replied that the university is working closely with press, churches and other community institutions, as the community has grave concerns about the quality of care.
· Mark Gamble of HASC commented that the transition was remarkably seamless, with both sides rallying. HASC continues to work with LACDMH on behavioral health issues. The lack of “brick and mortar” and workforce creates capacity issues for South L.A.
· Regarding whether Drew University’s strategic plan includes contingency plans and dialogue with the private sector, Dr. Kyle replied that conversations have taken place with LACDMH, CMAC, Medi-Cal and other agencies.
Ms. Vera pointed out that Dr. Robert Splawn, Chair of the EMS Commission, had provided information on recently passed motions (Attachment B).
D. Community Clinics
Gloria Rodriguez, CEO of Community Clinic Association of Los Angeles County, spoke on the impact on ambulatory care and the loss of the residents. CCALAC and LACDHS will engage in joint planning of coordinated ambulatory care services starting in January 2007. Drew University plays an important role as an area health education center, placing medical students in community clinics and increasing the pipeline of diverse physicians and allied health professionals. The Southside Coalition of Community Health Centers (SCCHC) has developed a specialty clinic. SCCHC is having conversations with LACDMH, as the specialty clinic is a natural site to locate mental health services. Nina Vaccaro, Director of SCCHC, mentioned that they have developed the clinical footprint for a specialty care clinic at Orthopedic Hospital, which includes cardiology, ultrasound and gastroenterology, as there is a great need for services. Richard Veloz, Chair of SCCHC and CEO of South Central Family Health Center, said the need for a medical home stands out. Based on a feasibility study, access to primary and specialty care was identified as priorities. The clinic was developed since a six-month to two-year wait list for specialty care exists. Since its start, the clinic has provided 300,000 visits to almost 50,000 users. The answer to addressing the lack of health care access is to improve partnerships, as we cannot solve these problems in isolation.
Dr. Robert Ross, CEO of The California Endowment, asked if this was a crisis as opportunity moment, given the development of the SCCHC and MetroCare and the need for primary and specialty care. He suggested banding together and leveraging political support to make a special HRSA funding request to address the crisis. Jim Mangia, SCCHC Treasurer and CEO of St. John’s Well Child and Family Center, said that SCCHC met with Elizabeth Duke, HRSA Director, on primary and specialty care concerns and received a HCAP Grant to set up its specialty clinic. Ms. Rodriguez mentioned that it will take political effort and will to get additional money from HRSA. Bill Hobson, Member of SCCHC and CEO of Watts Healthcare Corporation, mentioned that improving specialty care for the uninsured is dependent on effective referral relationships. There are no written agreements between PPPs and medical centers. Uninsured patients receive a referral to the county medical center and return to their medical home. Individuals seek care at MLKHH on an urgent care basis.
E. LACDHS
Dr. Bruce Chernof, Director and Chief Medical Officer of LACDHS, said that this is a crisis. We are three months from the CMS letter, and the challenges are not over. December 1st went smoothly. The political push to make it happen was tremendous. LACDHS has signed agreements with St. Vincent and St. Francis Medical Centers as well as other groups to provide services. Little steps have been taken, such as the time to being discharged decreasing. SPA 6 still has a hospital open in the community. We have to re-imagine how services are organized and delivered via the MACC, as academic medical centers are not patient-centered. Foundations are the driver of the political engine. The three issues that LACDHS still needs to address are: 1) Having a hospital that meets conditions of participation; 2) Providing family, community and patient-centered care; and 3) Building back inpatient services in partnership with HASC to 114 beds and deciding what that should look like.
Questions were asked, with the following answers given:
· Regarding the additional 22,900 visits that are projected to be provided under the MACC as compared to current volume, Antionette Epps Smith, CEO of MLKHH, said that a lot of demand has gone unmet due to the lack of capacity, with the need to expand services. It is anticipated that the MACC will provide 190,000 visits as projected. Dr. Chernof mentioned that the community clinic and SCCHC relationships will be important as LACDHS looks at new ways to deliver care.