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A State of Change: Delaware hospitals grapple with changing healthcare landscape

Delaware Public Media

Delaware is known as the “Small Wonder,” but when it comes to healthcare, the state is facing some big issues. Despite Delaware's size, the challenges can differ drastically for health care systems above and below the Chesapeake & Delaware Canal. They can even vary from Kent County to Sussex County. In this two-part series, contributor Pam George takes a look at how the state's hospitals are addressing the issues – together and apart. In her first piece this week, she examines New Castle County.

In 2013, when Brian Dietz arrived at Saint Francis Health System as the interim CEO, he was immediately struck by the cost of providing health care in Delaware. According to the Centers for Medicare and Medicaid Services, per capita healthcare spending in Delaware is among highest in the country.

Delaware has a large number of residents on Medicare and Medicaid, which lag behind private insurance when it comes to reimbursement rates. Their numbers are growing. Dietz became the president and CEO of the Wilmington hospital in 2014, the same year that Delaware adopted Medicaid expansion through the Affordable Care Act, which upped the number of Medicaid patients.

Meanwhile, the ACA has put pressure on hospitals to improve healthcare outcomes, a mission that typically involves hiring staff and buying equipment. But the emphasis is also on reducing costs.

Situated in Philadelphia’s looming shadow, New Castle County hospitals face competition from large systems attached to universities. Talk about keeping up with the Joneses. “It’s difficult to have the services offered locally at the prices necessary to be competitive when you’ve got the larger facilities up in Philadelphia,” Dietz noted.

Strength in Numbers

Like many industries, New Castle County hospitals historically combated rising costs by merging resources. Christiana Care Health System, for instance, is the result of the 1965 merger of Memorial Hospital, founded in 1888 as the Homeopathic Hospital; Delaware Hospital, founded in 1890; and Wilmington General Hospital, which opened as the Physicians and Surgeons Hospital in 1910.

The combined facilities and services became the Wilmington Medical Center. After the opening of Christiana Hospital in 1985, the name changed to Christiana Care Health System to reflect multiple locations and services throughout Delaware. Riverside Hospital, once an independent facility on the edge of the city, is now a campus.

Saint Francis Healthcare, founded in 1924 by the Sisters of St. Francis of Philadelphia, is now part of Trinity Health, a $15.9 billion organization with 96 hospitals in 22 states. “It provides tremendous clinical and professional resources that we can tap into to help us achieve our goals here in Delaware,” Dietz said. Trinity chose Saint Francis to be the alpha site for its new electronic health record system.

Nemours/Alfred I. duPont Hospital for Children, which opened in 1940, remains independent. But it has a second freestanding hospital in Orlando. (Founder Alfred I. duPont lived in Florida when he died and was active in the Sunshine State.)

Today, Delaware hospitals are pooling resources in other respects. In September, Christiana Care Health System, Bayhealth Medical Center, Beebe Healthcare and Nanticoke Health Services formed eBright Health, an alliance to share strategies to improve population health, treatments and outreach. The goal: reduce hospital admissions and unnecessary tests and leverage purchasing agreements for better deals.

The alliance is an extension of the statewide Quality Partners Accountable Care Organization (ACO) Medicare Shared Saving Program, which began in January 2016. The ACO focuses on Medicare populations. Along similar lines, Saint Francis is part of the Delaware Care Collaboration, a partnership between the healthcare system and the Medical Society of Delaware. If ACO groups are successful at lowering costs and improving care, they get a share of the savings.

However, eBright Health is not limited to Medicare patients. The hospitals will apply similar strategies across other populations.

Promoting a Healthier Population

“Population health,” the effort to improve the health of a segment of the population, is an industry buzz phrase. Typically, it applies to people with chronic – and often multiple – conditions that present higher levels of health risks and health care costs. Consider diabetes, heart failure or asthma. Population health initiatives are vital as health care moves from a fee-for-service reimbursement model to one based on outcomes.

Christiana Care Health System’s Care Link identifies high-risk patients and provides them with the tools they need to remain out of the hospital. The program monitors the patients’ progress in part through technology; patients use equipment at home to collect data, which is transmitted to Care Link team, which the includes case managers, pharmacist, nurses and behavioral health specialists. Team members can intervene if they spot warning signs.

Some patients were identified as high-risk through computer algorithms, which search about 50,000 patient records in the databases of Christiana Care and the Delaware Health Information Network.

The focus on value versus volume is also a priority at Nemours/Alfred I. duPont Hospital for Children.

“Primary care physicians are instrumental,” said Paul Kempinski, president of the Nemours/Alfred I. duPont Hospital for Children. “We’ve expanded through the acquisition of primary care physician practices the number of doctors Nemours employs and is affiliated with.”

Adding primary care physicians is one way to combat the overuse of the emergency department. “What I’ve been surprised at – compared to the other eight states I’ve worked in – is that utilization of emergency rooms in Delaware is extraordinarily high,” Dietz said. “There are a lot of people who don’t need the emergency room. It’s the most expensive care you can possibly deliver.”

For those who don’t have a primary care provider in Delaware, he’d like to see an increase in the use of accessible sites, such as walk-in care clinics.

An Outpatient Approach

Walk-in care is part of a trend toward accessible outpatient services. “All organizations are basically working to meet the trend of less care being provided on an inpatient basis and extending the reach into ambulatory and outpatient centers – including primary care physician offices,” Kempinski said.

Nemours recently opened Nemours duPont Pediatrics in Deptford, which  cost of $45 million. Within the 6,500-square-foot building are clinical and therapy services, an outpatient surgery center and onsite imaging.

Why New Jersey? There aren’t enough children in Delaware to support a leading pediatric hospital with high-level services such as open-heart surgery and bone marrow transplants. To remain competitive with Children’s Hospital of Philadelphia, Nemours has expanded into Pennsylvania as well as New Jersey.

Not all the expansions are independent operations. Nemours offers pediatric services to adult hospitals. For instance, Nemours plans to have a presence on the campus of Milford Memorial Hospital, which is currently under construction. There is also a clinic in Seaford.

Updating and Renovating

Given the move toward outpatient care, you might wonder why Nemours in 2014 unveiled a $272 million expansion – the largest in its history. However, the 144-bed towers did not up the total bed count. Instead, it offers single-patient rooms with sophisticated technology and space for parents.

Although the trend toward more outpatient services means there will be fewer children and adults in hospital, those who are admitted will be sicker than populations in the past and require extended stays. “The cases are more complex and chronic,” Kempinski said.

Hospitals must also renovate or expand to adapt to healthcare innovations and discoveries, such as machines that require additional space. They also must address the community’s healthcare needs. For instance, Christiana Care Health System averages more than 17 births a day. In 2017, the system plans to break ground on a $260 million, eight-story women and children’s building. A four-level, 750-space parking garage is expected to open in 2017.

Saint Francis, meanwhile, has focused on meeting the demand for emergency services within Wilmington’s city limits. “We see a lot of patients that require a level of care that we weren’t certified to provide ... gunshot wounds, stabbings and other levels traumas,” Dietz said. “We were transferring a lot of patients.”

The hospital recently was certified as a Level III Trauma Center. To receive accreditation from the American College of Surgeons, the healthcare system must demonstrate its capabilities for one year.

“While preparing to receive its certification, Saint Francis ramped up its blood bank supplies. Within a week after meeting that requirement, an emergency room patient needed a transfusion – we saved his life,” Dietz said.