Maintaining essential services in vulnerable communities is focus of report

February 15, 2017

Telehealth may be useful tool in care of medically underserved populations


At a time when health care is in flux, how do hospitals ensure that they do not leave behind those in low-income, inner-city or rural communities?


That question led the American Hospital Association to form a task force in 2015; its goal was to "provide vulnerable communities and the hospitals that serve them with the tools necessary to determine the essential services they should strive to maintain locally, and the delivery system options that will allow them to do so."

"If you look at statistics from the AHA, one out of three U.S. hospitals is struggling," said Robert J. Henkel, executive vice president of Ascension and president and chief executive of Ascension Healthcare. He chairs the AHA's Task Force on Ensuring Access in Vulnerable Communities.

For many in densely populated city centers and isolated rural areas, "the hospital is their only source of health care," said Henkel, who also is the 2016-17 chair of the CHA Board of Trustees. If those hospitals fail, he added, it will leave "more and more people who are the most vulnerable with no access to health care."

Stepping up
In its final report, issued Nov. 29, the AHA task force — which also included Patty White, president of Dignity Health St. Joseph's Hospital & Medical Center in Phoenix —concluded that "to fully ensure access to essential health care services, we will all need to do our part — vulnerable communities, the hospitals that serve them and the association that serves us all.

"Vulnerable communities will need to make significant investments of time, effort and finances," the report added. "Hospitals will need to build upon their current infrastructure for health information technology, patient and family education, care management and discharge planning."

The report outlined nine broad strategies (see sidebar) that hospitals can mix and match depending on the specific needs in their communities. These include transforming the hospital's inpatient/outpatient balance to better reflect the community's needs and enhanced opportunities for virtual care and monitoring of patients beyond the hospital's doors.

Remote monitoring
Henkel said he is most excited about the virtual care strategies mentioned in the report.

"The concept of virtual care strategies works well in both urban and rural communities, providing access that would otherwise not be possible," he said.

A rural health center with virtual care could allow "access to psychiatrists, cardiologists and other specialists without the patient having to go 50-75 miles," Henkel said. Such travel can cause particular problems for the frail elderly, he added.

In the cities, "almost everyone has a cell phone or some kind of device" that could be used to monitor patients remotely and provide immediate access to a health care provider for patients or their caregivers, he said.

"The potential (for virtual care) in both urban and rural communities has not begun to be tapped," Henkel said, describing the possibilities as "much broader" than what is known as telemedicine.

"Virtual care takes technology and begins to expand it to the individual," he said. "It allows more and more clinicians to consult with other clinicians, and it can provide remote monitoring that prevents people from having to go to the hospital or ER for the wrong reasons."

Ministry best practices
The report touts two Catholic health ministry members that demonstrated effective implementation of some of the strategies it recommends.

At Bon Secours Baltimore Health System, the establishment of a state-subsidized Health Enterprise Zone has helped to affect the social determinants of health by attracting additional health care providers to the area, providing fitness equipment in churches, offering healthy eating classes and medication management and other initiatives.

Our Lady of the Lake Regional Medical Center in Baton Rouge, La., implemented a number of strategies to meet community needs when the state-run Earl K. Long Medical Center closed in 2012. These included community meetings to raise awareness of the OLOL clinics available to former Long patients, enhanced staffing at the clinics to reduce wait times, building a separate pediatric emergency department and taking on local graduate medical education.

Vulnerable communities
The AHA report defined a vulnerable community as one in which the population is "much more likely to be in poor health and have disabling conditions," due to a lack of access to primary care services, poor economy, high rates of uninsurance or underinsurance, cultural differences, low education levels and/or environmental challenges.

Caring for those patients is at the core of the mission of Ascension and Catholic health care in general, Henkel said.

"Our mission is particularly focused on the poorest and most vulnerable," he said. "Catholic hospitals have made caring for vulnerable populations a priority and are often located in areas where health care is needed the most. That is what the ministry of Catholic health care is all about."

Care without walls
Although the work of the task force began long before the November 2016 elections, Henkel said the strategies outlined in the report may become even more crucial "as we hear discussions of repealing or replacing the Affordable Care Act, decreasing access most to the core populations who are at risk."

The Ascension leader said the AHA task force was created because "something needed to be done rather than continuing to press forward with thinking of health care the same way we always have."

Some of the strategies recommended in the report will require changes in federal or state laws or licensing requirements and the approval of demonstration projects at the federal and state level, Henkel said.

"We have to rethink the definition of hospital to a much broader view than acute inpatient care," he said.

With 29 hospitals and health systems represented on the task force, he added, "I sensed that people are looking for the ideas and assistance in order to think about the future and put all the pieces together."


Strategies to ensure access to health care

The American Hospital Association notes that one out of three hospitals in the U.S. are fighting for survival. It offers the following as potential areas for consideration by hospitals and rural and urban core communities working to safeguard health care access:

Social determinants of health: Screenings, navigation services and alignment of community and clinical services.

Global budgets: Fixed reimbursement for a population over a designated period of time, with community autonomy and flexibility.

Inpatient/outpatient transformation: Reducing inpatient capacity to align with community need and enhancing primary care and outpatient services.

Emergency medical center: Provides emergency and transportation services, without inpatient acute care services.

Urgent care center: Serves as access point for patients with urgent medical conditions that do not appear to be life-threatening but require care within 24 hours.

Virtual care strategies: Allow for 24/7 access to health care providers and high-tech monitoring options for patients.

Frontier health system: Facilitate delivery of coordinated health care services to isolated or low-population areas.

Rural hospital linkages: Connect rural hospitals and community health centers providing primary, behavioral and oral health.

Indian Health Service strategies: Foster partnerships between Indian Health Service and other health care providers to increase health care access for Native American and Alaska Native tribes.

Source: American Hospital Association report, "Task Force on Ensuring Access in Vulnerable Communities"


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