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Maine Hospital's Dilemma: Improved Care Shrinks Bottom Line
06/11/2014   Reported By: Patty B. Wight

Under the Affordable Care Act, the quality of health care you receive is supposed to improve. Hospitals, for example, are expected to reduce readmissions, cut down on unnecessary tests. But these are the kinds of services that have been the bread and butter of hospitals for years. Take them away, and the hospital loses money. So the challenge for hospitals is how to increase quality and still stay in business. Patty Wight visited one hospital in western Maine that's grappling with that task, and tonight she has the first of two reports on what she found out.

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Tracy Harty

Franklin Memorial Hospital nurse navigator Tracy Harty makes calls as part of the facility's effort to improve care.

In her 30 years of nursing at Franklin Memorial Hospital in Farmington, Tracy Harty has sported about a dozen different ID badges. "I'm currently a nurse navigator," she says.

As a navigator, part of Harty's job is to usher uninsured patients through the health system. On this day, she's checking on Mark Osgood, who is at the hospital because of a recent lung cancer diagnosis. "Your first treatment is Thursday morning," she says. "And, are you coming alone?"

Before his diagnosis, Osgood didn't have health insurance, so Harty helped him enroll. She'll keep helping him - with paperwork, or getting whatever community resources he needs.  

Osgood says it's a relief.  He can focus on getting better. "I need help," he says. "I mean, this is a desperate fight. I can't do this by myself.  I know I can't."

Last year the hospital spent more than $6 million providing care for the uninsured. Franklin County is the third poorest  in the state.  Charity care costs here are swelling.

So the hospital put Harty to work as a navigator to figure out what kinds of diseases were going untreated, to reduce costs by enrolling patients in insurance plans when possible, and to help patients take better care of themselves.

"We kind of went into this thinking it would probably be two or three chronic diseases that would be the culprit," Harty says. "And if it was diabetes and congestive heart failure, say, then we would just design programs to address those issues, and then we'd be all set."

The thought was that the hospital could treat a patient before their illness became acute.  But Harty's research turned up something unexpected.

"A lot of the $6 million is spent on catastrophic hospitalizations - people who have been sick for a period of time, have ignored that illness, and then they've had something major happen," she says.

The problems were much more complex and individualized than anyone imagined. As Harty worked with patients, she discovered that personal and social circumstances often trumped health problems. And she realized that if she wanted to get people healthy, she would need to first address their underlying issues.  

This is unchartered water for a hospital administartor or a nurse navigator. But Harty says it's crucial. "If they're living with mold in their basement and they have asthma or congestive heart failure, they're going to be sick over and over again -  until we ask the right questions," she says.

Harty's work has turned her into something of a medical sleuth. That mold-in-the-basement problem is a real example. She discovered it by going to a patient's home.

"Being able to put myself in someone's place where they live has just been an eye opener.  It's been humbling, and it's taught me so much," she says.

Patty Wight: "And then what do you  do - if you do see there's mold in someone's basement, what do you do about it?"
Tracy Harty: "I find out what their resources are to clean it.  And if they have no financial resources, then I start making phone calls, just seeing if I can get other services in. I call the local church to see if we can get someone to help out.  We had to help someone move into a hotel for a little while until they could get all the mold cleaned out of their house."  

This shift from a clinical to a more social focus is just one of the changes Franklin Memorial has made in recent years to improve quality.

"So its foundation is an initiative called 'Zero Defects,'" says Franklin Memorial Chief Operating Officer Jerry Cayer.

Cayer says the hospital used to gauge success by meeting a list of quality measures.  People would slap each other on the back, he says, when the hospital would achieve a 90 percent success rate.  Zero Defects flips that view and reports every time the hospital fails to meet a quality measure.  

Focusing on what went wrong completely changed the staff's outlook. "Well, suddenly you're not jumping up and down for joy, because that indicator that gets missed could very simply be your neighbor, your family member, your co-worker," Cayer says.

These weren't life-threatening mistakes.  But they are missed protocols that keep patients healthier. Take flu shots.  Every admitted patient to Franklin Memorial is supposed to be offered one.  But, for one reason or another, that didn't always happen.  So, Chief Nursing Officer Pam Ernest says flu shots became a Zero Defects initiative.

"So the outcome of that is, it used to be every February and March, we could anticipate we would be filled to the brim with patients with the flu, who were so sick from the flu, they had to be admitted," Ernest says. "I would guess that this past year, we had maybe had two inpatients that had the flu."

Franklin Memorial also targeted unnecessary Emergency Room use, such as patients with ear aches who use the ER more out of habit than necessity.

"So we started calling those patients to say, the following day, 'Are you feeling better?  Did you pick up your prescription?'" says Mavis Dubord, the hospital's clinical director. "And just to let you know, if that should happen again, there's a doctor on call 24 hours a day.  Call that doctor and we will see you in the office."

The idea is to get patients to focus on primary care, where treatment costs tens of dollars versus hundreds of dollars in the ER.  And the hospital has largely been successful.  In the past three years, ER admissions have dropped 15 percent. As for defects, in 2007, the year before the initiative was launched, the hospital identified nearly 200 defects.  In 2013, there were just 16.  

But COO Jerry Cayer says there's a catch to this success:  "We will have an operating loss for this fiscal year, which ends June 30th."

In fact, Franklin Memorial's operating revenue has dropped nearly $17 million over the past three years.  Increasing quality - and following the principles of the newly-enacted Affordable Care Act - has created a drain for money.  Now, Franklin Memorial has to figure out what might be an even bigger challenge than improving patient quality:  how to stay in business.

Our story continues Thursday on "Maine Things Considered" and

Photo: Patty Wight


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