Emergency Care Business Models

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Emergency Care Business Models

A rural hospital in Georgia established a freestanding emergency department after another local hospital had closed. This resulted in increased usage of the facility. The University of Mississippi Medical Center established the Center for Telehealth in 2013, and in 2017 it was named a Center of Excellence. The Center also has a program specific to emergency services that they estimate can save over $530 million annually. Below we outline our research strategies and provide our key findings.

Methodology

We began our research by looking for existing case studies of small and/or rural hospitals located in Canada, Europe, Australia, New Zealand, or Asia that have successfully changed their emergency department model in the past two years. To locate this data we searched medical sites such as ScienceOpen, Lens.org, the National Center for Biotechnology Information (NCBI), and PubMed. This allowed us to find a study on improving rural emergency care in Quebec, Canada published by the NCBI, and a report on Successful Models of Rural Health Service Delivery published by the New Zealand government. The New Zealand report was from 2001, and therefore not helpful, but there was some valuable information in the NCBI report even though it wasn't a case study of a specific hospital. Since searching within the past two years was not successful, we expanded our search and looked for case studies within the last five years. This led to an NCBI report on the effect of national reforms on improving emergency room access in Australia but did not provide any specific case studies to examine.
After determining that there were likely not any existing case studies that met the exact needs of this report, we proceeded to look for rural emergency rooms that had made innovative changes that resulted in increased use and profitability. We examined sites such as ScienceDirect, Joule, EuropePMC, and NEJM Catalyst. This led us to a report at ScienceDirect that discussed the policies that eight countries have implemented with regard to hospitals in rural areas. Although this again was not a specific case study, there was some relevant information that we included below.

Finally, as a last resort, we expanded our search to include case studies from the U.S. This allowed us to find relevant case studies that are included below.

Piedmont Mountainside Hospital's Freestanding Emergency Department

CHALLENGE
The North Georgia Medical Center (NGMC) in Ellijay, Georgia had been losing money for about a decade before finally closing their emergency department in March 2016, followed by the closure of their inpatient unit in June of the same year. This resulted in a lack of medical services for the residents of Ellijay and the surrounding communities. At the time of closure, the hospital was averaging 6 patients per day, which was not sustainable.

CLINICAL MODEL
Piedmont Mountainside Hospital (PMH) proposed leasing space at the shuttered hospital to open a freestanding emergency department. It took less than a year for PMH to make renovations to the space, bring in new equipment, and expand the lab services offered. The freestanding emergency department opened in April 2017. In addition to signing a five-year lease for the emergency department space, PMH also leased office space from NGMC. For staffing, the hospital transferred 15 employees from its existing staff and hired 35 more to ensure 24/7 operation of the facility.

SUCCESS METRICS
One year after the new facility opened, they were averaging 30 patients per day and there had been over 11,000 total visits to the freestanding emergency department. PMH also has a collaborative relationship with the Gilmer County EMS to ensure patients with higher level needs can be quickly and safely transported to a different facility.

IMPLEMENTATION BARRIERS
There were three main barriers to implementing the new clinical model.
  • Initial distrust in the community
  • Legal obstacles such as evaluations and approvals from both state and federal agencies
  • Complaints from area competitors who didn't want the emergency department approved.

A state politician who was a native of Ellijay, played a big role in communicating with all the stakeholders to ensure support for the facility.

TelEmergency program in Mississippi

CHALLENGE
Rural hospitals in Mississippi did not have the capability to provide many specialty services, including emergency care. Since these hospitals often had to transfer patients to other facilities, they lost reimbursements which resulted in financial struggles.

CLINICAL MODEL
The University of Mississippi Medical Center (UMMC) developed a telehealth program in 2003 to expand services at rural and remote hospitals. In 2013, the Center for Telehealth was launched.

Although the model provides for a variety of specialty services, one of them is emergency care. The program is called TelEmergency and it allows for specially trained Nurse Practitioners (NP) to connect with a variety of specialists at UMMC in real time through a telehealth connection. The team works together and the patient benefits from staying close to home and also receives top-notch care from experts.

SUCCESS METRICS
"In 2017, the Center was designated one of two Telehealth Centers of Excellence by the Health Resources and Services Administration, receiving $600,000 of grant funding for the initial year." This designation allows the program to serve as a clearinghouse for other programs providing telehealth services.

The Center of Telehealth now operates in over 200 locations and have reached over 500,000 patients. The TelEmergency program reports that it can save over 850,000 emergency transports with an annual savings of over $530 million.

Telehealth services can also reduce the need for staff at a rural location as any expertise needed can be accessed through the telehealth portal. Additionally, a study by the University of Iowa found that the length of stay in the emergency department was decreased for patients that utilized telemedicine.

IMPLEMENTATION BARRIERS
Many of the issues for the telehealth program are related to regulations. It is difficult for providers to offer services across state lines due to licensing concerns. Additionally, there have been issues with Medicare payment issues which have limited the growth of the program.

Hospitals in rural or remote areas: An exploratory review of policies in 8 high-income countries

Although this report is not a case study, it provided some relevant details related to how rural hospitals can remain open by changing their clinical model. The United Kingdom was one of the eight countries examined as part of this study. It found that the country does not have any specific national policy of remote or rural hospitals.

To obtain the required information for the study, key experts in each country were identified and they provided answers to the questions asked by the researchers. The UK experts indicated that there were very few hospitals in the UK that could truly be considered remote. However, they still were able to identify the major issues for hospitals that do fall into this category as staff recruitment and training. The UK experts from this study indicated that the main solutions were centralization of services, providing support to smaller hospitals, and creating networking arrangements between hospitals.

There has been some innovation seen at these more remote hospitals such as merging units sharing coverage in off hours to avoid issues with working time restrictions.

Rural emergency care 360°

The NCBI published a study that looked at recommendations for improving emergency medical services in Quebec, Canada. The paper actually outlined a study that was going to be done, rather than one that was already completed. However, just setting up the study allowed for findings of how rural emergency care can be improved. Some suggestions included remote monitoring, training of medical staff either through simulation programs or immersion programs, and improvement of care standards.
Sources
Sources

Quotes
  • "Through our literature review and the results of our earlier research, the expertise of our multidisciplinary team and the experience of our partners, we have already identified the following solutions that could improve accessibility, quality and cost-effectiveness in rural emergency care and services: improvement of emergency prehospital care (eg, optimisation of transfers); use of new technologies (eg, telemedicine, Point of Care Ultrasound); optimal use of resources (eg, access to medical specialists and facilities); training (eg, simulation-based learning) and improved management procedures (eg, facilitating the implementation of the ED management guide (‘Guide de gestion de l’urgence’); standardise databases for better measurement of quality indicators)."
  • "One promising solution is prehospital remote monitoring, whereby ambulance personnel and nurses can be supported from a distance."
  • "Rural physicians are requesting additional training. Simulation-based learning or clinical immersion programs are promising innovations in medical education that could meet the educational needs of rural emergency physicians."
Quotes
  • "The study identified moderate improvement in ED access as a result of the reforms (investment in infrastructure and workforce and the introduction of ED targets). Clinical leadership and support from management were essential for the improvement. Without ongoing investment and clinical redesign activities, however, sustainability of the improvement may prove difficult."
Quotes
  • "Common challenges include financial sustainability, medical education, telemedicine and transport."
  • "Where the population is more dispersed and distances are greater, access to hospital and emergency services may become problematic. Geographical distance could then lead to inequities in access and underutilization of emergency hospital services among populations in rural or remote areas. Concern has therefore been raised about the existence of “medical deserts” even in more densely populated countries such as France."
  • "The financial sustainability of small hospitals in rural or remote areas has become a major concern in terms of both capital expenditure and running costs, while attracting highly skilled staff to rural or remote locations has posed a further challenge. Yet, the closure of hospitals is often highly politically charged and resisted by the local population. In these contexts, primary health care has gained in importance, either through preventing unnecessary hospitalizations or through providing basic emergency care, sometimes assisted by telemedicine."
Quotes
  • "Because of freestanding ED regulations, PMH needed to go through evaluations and approval processes from state agencies (for instance, the State Fire Marshall) and federal agencies (for instance, the Centers for Medicare & Medicaid Services)."
  • "Despite their existing medical presence in Ellijay (cardiac imaging center, outpatient diagnostic center, MRI services, and a sleep center), the motivation behind PMH's move to start a freestanding ED was questioned by members of the community and caused uncertainty in staff who sought jobs elsewhere after the closure."
Quotes
  • "The Center for Telehealth was launched a decade later in 2013. Through the Center, patients and providers can access needed healthcare services through telemedicine technology."
  • "In 2017, the Center was designated one of two Telehealth Centers of Excellence by the Health Resources and Services Administration, receiving $600,000 of grant funding for the initial year. The designation allows the Center to serve as a national clearinghouse for telehealth research and resources, including technical assistance to other telehealth providers."
Quotes
  • "Participants were provided with tablets loaded with technology that allowed them to transmit their blood sugar directly to their RN Care coordinator. The preliminary results of the first 100 patients were remarkable: compliance with medication reached 96% and compliance with scheduled health sessions reached 83%. On average, these patients saw a 1.7% decrease in their A1C — a measure of blood glucose — and not a single participant from the first 100 patients in the study were hospitalized."
  • "One of those success stories can be found in Mississippi, where an innovative approach to telehealth at the University of Mississippi Medical Center has significantly expanded the number of patients served in a state where 54% of residents live in rural areas, and 64% have to drive at least 40 minutes for specialty care. It’s sorely needed there — the United Health Foundation put Mississippi in the 50th spot in its overall annual health ranking. That includes coming in 48th in preventable hospitalizations, 50th in infant mortality and 48th in access to primary care physicians."