Copyright 2010, All rights reserved

The North Shore-LIJ The North Shore-LIJ Center for Comprehensive Care at Center for Comprehensive Care at

Greenwich VillageGreenwich Village

A New Hybrid Model of Care to A New Hybrid Model of Care to Deliver 21Deliver 21stst Century Medicine Century Medicine

April 2011April 2011

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I. St. Vincent’s Catholic Medical Center

II. Community Health Needs Assessment Study

III. North Shore-LIJ Center for Comprehensive Care

• Free-standing Emergency Department

• Imaging Center

• Ambulatory Surgery Center

• Laboratory Services

• Un-programmed physician and program space

IV. Facilities

• Building challenges

• Conceptual Design

North Shore-LIJ Center for Comprehensive CareNorth Shore-LIJ Center for Comprehensive Care

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St. Vincent’s Catholic Medical Center – TimelineSt. Vincent’s Catholic Medical Center – Timeline

St. Vincent’s merges with CMC Brooklyn/Queens and Sisters of Charity of Staten Island

SVCMC Network formed

1849

St. Vincent’s founded by the Sisters of Charity

Bayley Seton transferred to

Sisters of Charity

St. Vincent’s takes control of St. Vincent’s Staten Island

1980 1999 2005 2007 2009 20102000

Transfers St. Vincent’s SI to

Bayonne Medical Center

SVCMC Network files for Bankruptcy St. Joseph’s Hospital closed

St. Mary’s Hospital closed

St. Clare’s closed

Caritas files for Bankruptcy- St. John’s closed- Mary Immaculate closed

- St. Vincent’s CMC files for Bankruptcy (4/6)- St. Vincent’s Med Ctr closed (4/30)

2003

Acquires St. Clare’s Hospital

SVCMC emerges from BankruptcyTransfers St. John’s Queens and

Mary Immaculate Hospital to Caritas Health System

HEAL 16 awarded to NS-LIJ UCC planned with VillageCare

NS-LIJ acquires SVCMC Homecare

Community Needs Assessment

Kick-off

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April 2010St. Vincent’s Closes

May 2010Lenox Hill Joins North Shore-LIJ Health System

June 2010HEAL Award to develop Urgent Care Center in Greenwich Village

August 2010North Shore-LIJ partners with community leaders and elected officials to conduct Community Health Needs Assessment Study

January 2011North Shore-LIJ receives CON approval for Urgent Care Center

March 2011Urgent Care Center opensSVCMC accepts North Shore-LIJ proposal for Center for Comprehensive Care

Post SVCMC Closure ActivitiesPost SVCMC Closure Activities

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Steering Committee Activities

•Discussion Paper #1 – Define Service Area (10/1/2010)

•Discussion Paper #2 – St. Vincent’s CMC Medical Center (10/27/2010)– The Origin of its Patients– A Review of Communities Receiving Care

•Discussion Paper #3 – Socio-demographic Description of the Service Area (12/3/2010)– Overview of Health Status Indicators

•Discussion Paper #4 – Post Closure Review – Service Area Access to and Utilization of Inpatient and Emergency Services (2/3/2011)

•Discussion Paper #5 – Projecting the Need for Inpatient Beds (In Draft)

To be completed

•Discussion Paper #6 - Results of Community Health Survey

•Discussion Paper # 7 - Identification of Service Area Health Needs and Service Gaps

•Discussion Paper # 8 – Recommendations for Community Health

Community Health Needs AssessmentCommunity Health Needs Assessment

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SVCMC Inpatient Discharges – Patient OriginSVCMC Inpatient Discharges – Patient Origin

1 dot represents 1 discharge

2009 SVCMC Inpatient DischargesPatient Origin

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9

10

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North Shore-LIJ Center for Comprehensive CareNorth Shore-LIJ Center for Comprehensive Care• A new hybrid model combing the emergency department access of a

community hospital with the specialized ambulatory services of a Diagnostic and treatment Center.

• A destination facility licensed as a division of Lenox Hill Hospital• Located in the former O’Toole Pavilion of SVCMC (162,000 bgsf)• Anchor Programs will include:

– New York’s first freestanding emergency center – 20,000 gsf• 24 Treatment bays; 320 -Slice CT; X-Ray

– Imaging – 12,000 gsf• CT, MRI, Ultrasound, Angiography

– Ambulatory Surgery – 14,000 gsf• 2 ORs

– Un-programmed space of 43,000 gsf pending completion of Community Health Assessment – Beds for clinical decision making, patient stabilization and treatment

• Center for Comprehensive Care wills serve as a new front door :– Integrate North Shore-LIJ health services into the fabric of the community;– Coordinate with existing providers and;– Triage patients to the most appropriate facility/providers

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A New Hybrid Model of Care to Serve as the Front Door A New Hybrid Model of Care to Serve as the Front Door for Community Residents to Access Health Services for Community Residents to Access Health Services

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To support clinical integration across the care continuum by sharing of clinical data to support safe, effective and efficient practice and an enhanced experience for patients by:

Connecting patients and physicians in the community to support delivery of cutting-edge care

Coordination of care across practitioners, communication among practitioners, and seamless transitions in care between environments

Management of entire “episodes of care” across practitioners and environments supported by proven care guidelines

Improvements in the quality of care delivery and facilitate participation in quality initiatives Community

PhysiciansOther Health

Providers

NS-LIJCCC

Hospitals

RHIOs

Pharmacies

Labs

Home Care

Radiology

North Shore-LIJ’s Vision for a Connected CommunityNorth Shore-LIJ’s Vision for a Connected Community

NSLIJ CCC NSLIJ CCC Patients & Patients & FamiliesFamilies

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•Defined by the Community•Population of 385,000 residents

– 13.2% age 65 and over•2.2% population growth next 5 years•Payor Mix

– 39.7% Medicare– 29.7% Medicaid– 22.8% Commercial– 7.8% Self-Pay

Service AreaService Area

Primary Service Area (PSA)

Legend

Secondary Service Area-I (SSA-I)

Community Board border

Former SVCMC site

Secondary Service Area-II (SSA-II)

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Other Manhattan

2,810 (14.5%)

Service Area6,824

(35.2%)

Beth Israel11,674 (28.5%)

SVCMC6,824 (16.7%)

Bellevue4,561 (11.1%)

NY Downtown3,739 (9.1%) NYU

2,540 (6.2%)

All other11,577 (28.3%)

Manhattan9,634 (49.7%)

Brooklyn3,796 (19.6%)

Queens2,177 (11.2%)

Bronx1,149 (5.9%)

Staten Island384 (2.0%)

Other NYS910 (4.7%)

All other1,338 (6.9%)

Source: SPARCS ver06.10.10jpl

SVCMC and Service Area Inpatient Discharges, 2009SVCMC and Service Area Inpatient Discharges, 2009

SVCMC Inpatient Discharges(N = 19,388)

Inpatient Market Share(N = 40,915)

•Service Area residents accounted for 41,000 Inpatient Discharges– 17% went to SVCMC

• Service Area accounted for 35% of SVCMC Inpatient Discharges– 50% of SVCMC Inpatient Discharges came from outside Manhattan

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Service Area19,410 (40.6%)

Other Manhattan

6,816 (14.3%)

Beth Israel23,391 (26.8%)

SVCMC19,410 (22.3%)

Bellevue14,158 (16.2%)

NY Downtown10,757 (12.3%)

NYU4,460 (5.1%)

All other14,996 (17.2%)

Manhattan26,226 (54.8%)

Brooklyn7,841 (16.4%)

Queens3,972 (8.3%)

Bronx3,084 (6.4%)

Staten Island615 (1.3%)

Other NYS 1,693 (3.5%)

All other4,391 (9.2%)

Source: SPARCS ver06.10.10jpl

SVCMC and Service Area Treat & Release ED Visits, 2009SVCMC and Service Area Treat & Release ED Visits, 2009

SVCMC T&R ED Visits(N = 47,822)

Service Area T&R ED Visits(N = 87,172)

•Service Area residents accounted for 100,000 Emergency Visits•87,172 were Treat and Release Visits

– 38% Medicaid– 24% Self-Pay

•Almost 20,000 occurred at SVCMC•Another 28,400 Treat and Release visits seen at SVCMC were from outside the Service Area

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2009 Service Area ED Visits (Treat & Release)(n = 87,172)

19,837

18,364

6,0348,286

5,247

3,175

16,722

9,507

Non-Emergent

Emergent/PCP TreatableEmergent/PCP Preventable

EmergentDrug Alcohol

InjuryPsychiatric

Other

22.8%

21.1%

6.9%9.5%

6.0%

3.6%

19.2%

10.9%

Service Area ED Visits, 2009 Service Area ED Visits, 2009 – – NYU AlgorithmNYU Algorithm

Sources: NYU Algorithm; NYS DOH SPARCS ver01.03.11

2009 Service Area ED Visits (Treat & Release)of SVCMC

(n = 19,410)

17.9%

18.4%

5.9%

8.4%8.9%3.

4%

27.2%

9.9%

3,472

3,576

1,139

1,6371,737

652

5,281

1,916

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Free-Standing Emergency DepartmentsFree-Standing Emergency Departments

• FSED have existed for almost 40 years

• As of 2008 there were 222 operating in 16 states

• 191 of these are satellites /divisions of hospitals

• Traditionally, developed in response to access in rural areas, growing suburban,

overcrowding and where a hospital has closed

• Open 24 /7 – 365 Days

• Most accept all patients regardless of insurance income

• Don’t offer trauma services

• 911 Receiving Facility

• CMS certifies as off-campus Emergency Department

• Joint Commission accreditation provided through the affiliated hospital

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Center for Comprehensive Care Center for Comprehensive Care Free-Standing Emergency DepartmentFree-Standing Emergency Department

• Division of Lenox Hill Hospital• 24-hour access to Board-Certified Emergency Physicians;• 24-hour access to specialist consultations through North Shore-LIJ’s physician

network;• Inpatient beds for stabilization and clinical decision unit;• 911 receiving facility based upon protocols developed with EMS medical

control;• Rapid transfer via the North Shore-LIJ ambulance network to an appropriate

receiving hospital chosen by the patient or Lenox Hill Hospital;• On-site imaging, diagnostic and laboratory testing capabilities;• A Picture Archiving and Communication System (PACS) that will transmit

images to North Shore-LIJ radiologists, who will quickly interpret results; • An inter-operable Electronic Medical Record accessible to all providers in North

Shore-LIJ network who provide post-visit care to the patient; • The ability for patients to actively participate in their care and decide which

doctors or hospitals they will go to for follow-up care

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Center for Comprehensive Care Center for Comprehensive Care Free-Standing Emergency DepartmentFree-Standing Emergency Department

• Coordinated follow-up care to either the patient’s physician, a neighboring primary care provider or a range of specialists;

• For those returning home who require in-home assistance, access to the home care provider of their choice or services provided through the North Shore-LIJ Home Care Network;

• Follow-up referrals to manage a patient’s chronic conditions or other medical issues discovered during the course of treatment;

• Referrals to preventative care or education and support programs that will help avoid illnesses or injuries from worsening;

• An emergency care center that is accountable and meets all the same regulatory standards as traditional on-site hospital emergency departments (The Joint Commission Accreditation, NYS Article 28 and US Centers for Medicare and Medicaid Services).

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Compliance with Regulatory RequirementsCompliance with Regulatory Requirements• An emergency care center that is accountable and meets all the same

regulatory standards as traditional on-site hospital emergency departments • EMTALA• 911 Receiving and EMS • NYCRR Title 10

– Emergency Department and Services • 405.19• 708.5 (h)

– New Hospital Construction• 712-2.4

• CMS hospital off-campus Emergency Department Regulations– 42 CFR 413.65

• The Joint Commission Accreditation

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Free-Standing Emergency DepartmentFree-Standing Emergency Departmentwill meet the same NYS regulatory standards as an on-site will meet the same NYS regulatory standards as an on-site hospital emergency departmentshospital emergency departments

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• CMS provides requirements for Provider-based Off-campus Emergency Departments

• Must demonstrate compliance with the hospital Conditions of Participation and with the provider-based regulations at 42 CFR 413.65.

• Demonstrate how the off-campus emergency department will meet the emergency needs of its patients in accordance with accepted standards of practice for hospital emergency departments.

Recognized by the Recognized by the Centers for Medicare and Medicaid Services (CMSCenters for Medicare and Medicaid Services (CMS) )

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North Shore-LIJ North Shore-LIJ Emergency Department Capabilities Emergency Department Capabilities

Similar to that of a community hospital, including advanced life support services, our emergency clinicians will be able to treat a full range of illnesses and injuries, including—but not limited to—the following:

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Triage, Treatment Protocols and Transfer AgreementsTriage, Treatment Protocols and Transfer Agreements

• Will work with DOH and EMS to develop medical protocols with respect to which patients are appropriate to receive care at the Center.

• Exclusions as per 405.19 (3):

– Trauma and multiple injury patients;

– Burn patients (moderate to major);

– High-Risk maternity patients;

– Neonates or Pediatric patients in need of intensive care;

– Head-injured or spinal-cord injured patients;

– Acute psychiatric patients;

– Replantation patients;

– Dialysis patients, and;

– Acute myocardial infarction patients including those with ST elevation.• Transfer Agreements will be developed with Beth Israel, Bellevue (Trauma),

NYP-Weill/SIUH (Burns)

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Free-Standing ED Demand Model Free-Standing ED Demand Model

Service Area '09 SVCMC Projected EDTreat & Release Share T&R

PSA 27,405 55.1% 15,100 SSA-I 12,290 17.3% 2,126 SSA-II 47,477 4.6% 2,184

Service Area 87,172 22.3% 19,410

Projected ED T & R Visits 19,410

25% Inmigration1 6,740

6% Admitted2 1,652 Sub-Total 27,8023% annual growth for 5 years 4,116

Total 31,9181 In 2009, SVCMC ED Inmigration was 59%2 In 2009, SVCMC Admitted 22% of ED visits

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FQHC, DTC, Extension Clinics and Comprehensive ClinicsFQHC, DTC, Extension Clinics and Comprehensive Clinics

Source: NYS DOH(http://www.health.state.ny.us/nysdoh/hcra/provider/provamb.htm); accessed August 2010

Callen Lorde Community Health Center356 West 18th Street, NY 10011

Village Care Health Inc121A West 20th Street, NY 10011

West Midtown Management Group311 West 35th Street, NY 10001

Mount Sinai HospitalBayard Rustin Education Complex (PCP Clinic) West 18th Street, NY 10011

Beth Israel Medical CenterChelsea Medical Practice and Sr. Health (PCP Clinic) 277 8th Avenue, NY 10001

There are 41 Article 28 licensed providers in the Service Area. Most of the licensed ambulatory providers are north and east of Center for Comprehensive Care. VillageCare and North Shore-LIJ have a strategic partnership for the provision of urgent care services.

Legend

ABC Primary Service AreaABC Secondary Service Area

Diagnostic and Treatment Centers (DTC)

Center for Comprehensive Care

Comprehensive Clinics

Hospital-based Extension Clinics

Federally Qualified Health Centers (FQHC)

Reconciling two public goals:• Landmark – Preserve this historic structure• Healthcare – Design for 21st century medicine

Redeveloping a Landmark for 21st Century Healthcare

HISTORICAL CHALLENGES• Iconic design, dating to 1964, designed as a union hiring hall • Subsequent SVCMC adaptation to clinic not workable to today’s HC delivery • Subject of intense community attention and support • Original design is largely unchanged, and has aged • Deteriorating exterior materials • Building envelop is not energy efficient

LANDMARKS PRESERVATION

• Subject to LPC review, seeking “Certificate of Appropriateness”• Restrictions on modifications to building exterior• Cannot demolish and replace with a more efficient building• LPC process will impact renovation costs • Vertical expansion is severely limited

DESIGN CHALLENGES

• Significant structural work needed to insert ambulance bay• Need to reshape first floor to insert ambulance bay and public entrance• Shear wall element frustrates adaptation

Original floor plan Elliptical Plan Difficult to Secure

DESIGN CHALLENGES

• Double façade (concrete panels and window wall behind) costly to repair• Minimal fenestration at upper floors

INFRASTRUCTURE CHALLENGES• Mechanical / Electrical systems need replacement• Low floor to floor heights (first & second floors) • Significant abatement scope • Need structural reinforcement to support major equipment• Elevators need replacement and relocation• Need to replace/relocate two stairs

INFRASTRUCTURE• Mechanical / Electrical systems need replacement• Low floor to floor heights (first & second floors) • Significant abatement scope • Need structural reinforcement to support major equipment• Elevators need replacement and relocation• Need to replace/relocate two stairs

SITE CHALLENGES

• Open space to the south makes the building very visible from afar • Proximity to subway inhibits entry design at 7th Avenue• Proximity to subway entry requires extra care during construction• Lot line adjacency to neighboring buildings• Existing plinth/fence need replacement

PROGRAM

• Emergency Department• Imaging Diagnostic and Treatment unit (MRI, CT, US, Radiology, Mammo) • Ambulatory Surgery and future Angiography• Physicians Practices (future)• Clinical Services and Building Support

Preliminary Study

PROGRAM

• Emergency Department• Imaging Diagnostic and Treatment unit (MRI, CT, US, Radiology, Mammo) • Ambulatory Surgery and future Angiography• Physicians Practices (future)• Clinical Services and Building Support

Preliminary Study

DESIGN CONCEPT

• Ensure easy comfortable access for patients and ambulances• Continuing and improving use of natural light with new glass block / windows • Developing access to upper floors with a new entrance/lobby at W. 13th st.• Ensuring patient/visitor comfort with building environmental control systems

Preliminary Study

DESIGN CONCEPT

• Ensure easy comfortable access for patients and ambulances• Continuing and improving use of natural light with new glass block / windows • Developing access to upper floors with a new entrance/lobby at W. 13th st.• Ensuring patient/visitor comfort with building environmental control systems

Preliminary Study7th Avenue – Walk-in Entrance

DESIGN CONCEPT

• Ensure easy comfortable access for patients and ambulances• Continuing and improving use of natural light with new glass block / windows • Developing access to upper floors with a new entrance/lobby at W. 13th st.• Ensuring patient/visitor comfort with building environmental control systems

Preliminary Study W. 13th Street – Patient Entrance

DESIGN CONCEPT

• Ensure easy comfortable access for patients and ambulances• Continuing and improving use of natural light with new glass block / windows • Developing access to upper floors with a new entrance/lobby at W. 13th st.• Ensuring patient/visitor comfort with building environmental control systems• Considering inclusion of skylight to bring natural light to the upper floors

Preliminary Study

W. 12th Street – Ambulance Entrance

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• To better align community needs and resources, the Commission recommends that the state and industry collaborate to test and develop new “hybrid” delivery models.

• Such hybrids would maintain features of a traditional hospital determined to be necessary while eliminating redundant and unneeded features.

• Creative and financially viable alternatives, such as free standing emergency rooms or community health centers with urgicare capabilities, could advance the achievement of a right sized and restructured health care delivery system.

• The benefits could include enhanced access to services, less duplication, and amelioration of the economic impact of full hospital closures.

~Page 79

North Shore-LIJ Comprehensive Care Center North Shore-LIJ Comprehensive Care Center A New Hybrid Model of Care to Deliver 21A New Hybrid Model of Care to Deliver 21stst Century Medicine Century Medicine