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For Safety Net Hospitals in New Jersey’s Cities, the Challenges Are Many

How urban hospitals are using innovative programs to reduce cost and improve the health of their communities.

While NJ Spotlight is on winter hiatus, we've asked some of the state's thought leaders to share their opinions and expertise with our community. We'll be back, rested and ready, next week.

We all know that hospitals are critical, 24-hour, seven-day-a-week resources that serve us in countless ways as healthcare providers, economic engines, and protectors of public health. Clearly, their communities depend on their presence. But those located in New Jersey’s urban centers face the additional challenge of treating poor and uninsured patients with multiple chronic conditions, as well as social and housing needs.

Safety net hospitals provide services that frequently are in greater demand among patients living in cities. These include such things as intensive care, trauma care, specialized cardiac and diabetes care, dialysis, geriatric care, HIV/AIDS services, psychiatric care, and substance abuse treatment -- among others.

Urban hospitals not only provide specialty and emergency care, but also through their clinics and ER, meet many patients’ primary care needs that suburban insured patients may seek elsewhere. Time after time, those asked why they came to the hospital’s emergency room respond that it is trusted, friendly, knowledgeable, and a one-stop shop where all their healthcare needs can be met.

This is occurring while policymakers in New Jersey and across the nation are debating how to increase primary care access and reduce inappropriate utilization of the emergency room. Consideration has been given to implementing copays for low-acuity visits like colds and earaches. The premise is that these copays would serve as a deterrent to ER use.

But many hospitals have been the trusted caregiver in their communities for more than a century, and behavior change is tough and slow to occur. Rather than trying to change the access point of care, we must turn our attention to innovative programs to rightsize and coordinate that care.

Given their mission to their communities, urban safety net hospitals have done just that. In fact, it has been in our state's urban hospitals where models of national reform to promote comprehensive and efficient care that treats the whole person have begun.

So often it is a patient’s social and housing needs that contribute to poor health and reliance on the ER. Consistent with the concept of treating the whole person, East Orange General Hospital opened an on-campus Supportive Housing Facility providing homeless, mentally ill individuals with necessary services so they can achieve independence and reduce the cycle of evictions, hospitalizations, and homelessness.

To address chronic conditions like diabetes, asthma, and heart failure, many safety net hospitals have established disease management programs that both improve health outcomes and reduce healthcare costs. At Jersey City Medical Center, proven case management techniques for discharged congestive heart failure patients have reduced readmission rates by 45 percent.

A stellar example of urban hospitals revolutionizing care delivery is Dr. Jeffrey Brenner’s Accountable Care Organization Model in Camden -- America’s poorest city -- which brought together Cooper University Hospital and area providers and clinics to coordinate patient care for those who routinely accessed the ER. By analyzing emergency room utilization data to determine hot spots in the city where high ER utilizers lived, Brenner’s model focuses on increasing the number of medical professionals in cities to ensure patients follow necessary treatment plans. This “putting feet on the street” costs more in the short term, but saves significant money over time by managing ambulatory care-sensitive conditions like diabetes and asthma.

Coordinated care models like Brenner’s have been replicated in other major New Jersey cities like Trenton, Atlantic City, and Newark. Newark Beth Israel Medical Center even participated in an ER Diversion Program that placed an Advanced Practice Nurse in the emergency room to understand why patients used the emergency room and to coordinate their follow up by making subsequent appointments in hospital clinics. Programs such as this also have front-end costs but will help to “bend the cost curve” in the long run.

A big component to cost savings is eliminating unnecessary and duplicative medical testing. Just this month, eight North Jersey hospitals unveiled Health-e-cITi-NJ, a health information exchange that will allow providers to share medical information. City hospitals like St. Joseph’s Regional Medical Center in Paterson and Christ Hospital in Jersey City will be able to share electronic medical records with one another, area physicians, and pharmacies to improve healthcare delivery while reducing unnecessary healthcare costs. This is yet another example where upfront costs lead to long term savings.

Both New Jersey’s Medicaid Waiver application and the federal Affordable Care Act include demonstration projects to incentivize care coordination and promote healthy outcomes like the ones already underway at many of NJ’s urban hospitals.

We must keep in mind that the patient population at urban hospitals is made up in significant part by poor and uninsured patients, ranging from one-quarter to two-thirds of all patients who are treated at the hospital. That means at some places like University Hospital in Newark, for example, for every five patients, three rely on Medicaid or charity care to meet their needs. But it is in these same places where hospitals and their clinics, if equipped with proper financial support, are poised to make good healthcare policy changes resulting in lower costs and healthier populations in our cities.

With all of these innovative, cost-saving programs currently underway, the question is not how do we get away from city residents accessing the hospitals, but how do we ensure that each hospital can serve as a proper medical home for the people they serve. Instead of providing episodic care, the hospital can serve as a home base that offers whole person care that is connected to a wide range of social and health-related services.

The way to decrease inappropriate utilization of the emergency room is not by using artificial deterrents like copays -- but instead by multiplying the successes we have already had by investing dollars to increase care management in the very hospitals these patients know and trust.

Suzanne Ianni, M.P.H., is the president and chief executive officer of the Hospital Alliance of New Jersey, a coalition of fifteen of New Jersey’s urban safety net hospitals. For the last eighteen years, she has participated on numerous state committees dealing with access to healthcare for NJ’s most vulnerable populations. As a policy advisor, she has been called upon by both the administration and the legislature to provide input on critical healthcare issues facing New Jersey.

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