Dartmouth-Hitchcock Medical Center in Lebanon. Courtesy photo.
A large population of nurses are aging into retirement, and there’s not enough new recruits to replace them. There’s a shortage of community behavioral health resources and available beds—a challenge exacerbated by the opioid crisis. As baby boomers enter their retirement years, the medical needs of the community are changing. Cost of care continues to rise, while reimbursements from some insurance plans remain the same—low.
While local hospitals face huge challenges to providing the best treatment for their patients, many hospital CEOs say they are tackling these challenges head on.
Staffing and Housing Challenges
New Hampshire is tied for second in the country for low unemployment, which hovers around 2.7 percent statewide, with some cities and towns experiencing an even lower rate. While that should be good news, it only adds to the staffing headaches faced by hospitals.
“We are seeing it in every single area of professional practice,” says Joanne M. Conroy, MD, CEO and president of Dartmouth-Hitchcock, the largest health care system in the state. “Even in support functions—housekeepers, medical assistants, licensed nursing assistants. [It’s caused by] not only the fact that our population is aging, but our workforce is aging as well. And we are almost at zero unemployment to date. So the ability to attract and retain a young workforce is a challenge for everybody in the state.”
The most pronounced shortage for many hospitals in NH is in nursing, and it’s only expected to get worse. According to the American Nursing Association, “By 2022, there will be far more registered nurse jobs available than any other profession, at more than 100,000 per year. With more than 500,000 seasoned RNs anticipated to retire by 2022, the U.S. Bureau of Labor Statistics projects the need for 1.1 million new RNs for expansion and replacement of retirees, and to avoid a nursing shortage.”
But it’s more than just an aging workforce, Conroy says. She also argues that other factors such as the lack of affordable housing and the relatively rural nature of NH also contribute to the difficulty of attracting more nurses.
The new grads she’s spoken to, Conroy says, typically want to live in more metropolitan places right out of school, which leaves most hospitals north of Manchester out of the running. Further, she says, the cost of buying a home across the state, and particularly in the Upper Valley where Dartmouth-Hitchcock is located, is high.
“We are the second most expensive place to live in the state next to Portsmouth,” she says. “The average price of a home up here is $522,000. And it’s not any better across the river in Vermont where the average home is $524,000. I mean, the median income in the state is $76,000.”
Conroy says the hospital is working with local officials to advocate for more affordable housing in the area. But in the meantime, she says, Dartmouth-Hitchcock has developed training programs aimed at locals in an attempt to beef up its
The first of these initiatives is an apprenticeship program where licensed nursing assistants learn on the job, she says. After they complete the program, they are guaranteed a job at the hospital, which in turn leads to nursing certification. Conroy says the current class has about 36 apprentices.
Other hospitals are also increasing training to fill the nursing gap. Dean M. Carucci, CEO of Portsmouth Regional Hospital, says the hospital is sponsoring international nurses to help address the shortage. The hospital is sponsoring two nurses, with the expectation of growing to eight by the end of the year, Carucci says.
Portsmouth Regional Hospital also launched a post-degree internship program, which allows new grads to work at the hospital and gain hands-on experience and the opportunity to improve their skills in simulation labs at the hospital for four months. If they pass the program, the graduates are guaranteed a job at either Portsmouth Regional Hospital or Parkland Medical Center in Derry, both operated by Hospital Corporation of America. Carucci says the hospital is training its fourth set of interns. Since starting the program, classes have doubled from 12 to 24 participants, Carucci says, with about 85 percent landing a job.
The majority of the interns are being trained in medical-surgical nursing or critical care, but a handful are also being trained as psychiatric nurses to stem the growing shortfall in that sector. “Those are the hardest positions—at least in our experience—to fill at this time,” Carucci says, adding the plan is to keep growing the program with an emphasis on training behavioral health nurses. “Because even without the nursing [shortage], there’s an even greater demand within behavioral health.”
Behavioral Health and the Opioid Crisis
As of late April, 40 people have died from opioid overdoses in NH, with 86 cases pending toxicology results, according to the NH Office of the Chief Medical Examiner. Last year, 483 died from overdoses, an increase of 140 percent during the past six years. Meanwhile, a steadily increasing number of people in mental health crisis continue to spend days and weeks on end in hospital emergency rooms waiting for a treatment bed.
According to a report issued by the Health Research Institute in late 2017, “While the number of inpatient beds available in New Hampshire has declined over the years, there has recently been an upward trend, with inpatient capacity increasing from 430 to 458 beds from 2016 to 2017 alone. Despite this increase, however, the wait-list for beds has continued to increase.
While this suggests that adding beds would not in itself alleviate the problem of ER boarding, the upward trend in boarding occurred despite an increase in community-based services under the Community Mental Health Agreement during this period as well.”
Whatever the drivers, hospitals across the state are continuing to grapple with how to increase behavioral health services to meet the needs of the community. While some have been stymied by a lack of available staffing and funding to keep behavioral health and inpatient programs going, forcing them to close units and shutter programs, others are still looking at solutions.
At Portsmouth and Parkland, for example, Carucci says they have taken steps in the past 36 months to address this issue, including adding eight behavioral health beds at Portsmouth Hospital, bringing the total to 30 there and 14 at Parkland. They also began taking on involuntary patients, making Portsmouth Regional Hospital one of five designated receiving facilities in the state.
“We started with eight last year, and we added an additional four in response to the crisis and the plea from the governor and the commissioner of DHHS [Department of Health and Human Services],” he says. “So we went and jumped that from eight to 12 beds. We’ve also added two outpatient programs in the state, one over in Derry and one over in Hampton on the Seacoast. We did that in 2017 and that filled, quite frankly, in the first 35 to 40 days just because of the demand.”
Mike Rose, CEO at Southern NH Health, says behavioral health is “an area where there is significant unmet need in this community,” but adds the Nashua-based hospital has been doing what it can to meet that need. This includes increasing inpatient mental health bed capacity by 50 percent from 12 to 18 beds, doubling the size of its partial hospitalization program and establishing an intensive outpatient addiction treatment program.
Emergency Department bed at Southern NH Health. Courtesy photo.
“But still there is significant unmet need,” Rose says. “So we’re working very hard, partnering with providers of behavioral health to make sure that we’re working in a collaborative fashion and as efficiently as possible and that we’re coordinating care across that spectrum to make sure that we are doing everything we can be doing.”
But hospitals can’t do it alone. Rose notes that mental health services have been woefully underfunded for decades. And as a result, he says, there is a shortage of mental health professionals. “It’s going to take time to rebuild the mental health system,” he says. “That’s a decades long process to build up the necessary workforce for treatment.”
In 2011, the NH Center for Public Policy Studies predicted that by 2030, “nearly half a million Granite Staters will be over the age of 65.” The now-defunct center called it a “silver tsunami” that would represent almost one-third of the population.
New Hampshire hospitals are already seeing the effects of this transition and attempting to react in real time to shifting care needs as well as prepare for what’s to come. “There are 10,000 baby boomers a day that are turning 65,” Rose says. “And in New Hampshire, that’s even more pronounced because we had so much in-migration in the southern part of the state.”
“So our business is rapidly changing,” Rose says. “Ten years ago, about 27 percent of our business was Medicare; we’re at about 38 percent [now], and by 2030, we expect that to be half of our business.” And that can have a huge impact on a hospital’s bottom line when you consider that Medicare pays about 90 percent of the cost of care. Simply put, he says, that means, “half of our business in 12 years will be Medicare at 90 percent of the cost. So as that shift continues to occur, every year, for essentially the same book of business, we end up losing about $2 million in reimbursement.”
He says hospitals regularly look for efficient ways to deliver care as well as ways to partner or affiliate with other institutions to cut down on costs, share administrative functions and offer more services.
In the meantime, Rose says, Southern NH Health and other hospitals are planning for a shift in the types of services they will have to offer, including an increase in chronic diseases like diabetes, congestive heart failure and COPD. Hospitals will need to have sufficient specialty services in place to help manage those diseases and the increasing demand for those services.
“We’re gearing up to do everything we can to make sure that we are managing the overall health of patients with chronic disease in a manner that keeps patients out of high cost settings like the emergency room, or inpatient admission,” Rose says, explaining hospitals are focused on providing better proactive care in an outpatient setting.
Among the most prevalent hospital trends in NH is consolidation, Rose says. Hospitals are merging into multi-hospital systems or being acquired by existing large systems. While it’s been happening nationally for a while, in recent years, it’s started to take hold and accelerate in NH.
Staffing and reimbursement shortages and rising costs make it difficult for small community hospitals to offer the level of care they historically did, which has led to these acquisitions and affiliations, Conroy says.
Until five years ago, the state was dominated by stand-alone hospitals. But in the last few years, Massachusetts General acquired Wentworth-Douglass; Dartmouth-Hitchcock affiliated with Cheshire Medical Center, Alice Peck Day, and New London Hospital, as well as Mount Ascutney Hospital and Visiting Nurse & Hospice for NH & VT in Vermont; and Catholic Medical Center, Huggins Hospital and Monadnock Regional Hospital formed an affiliation called GraniteOne Health. The affiliation allows them to collaborate more closely on certain clinical and operational functions. Southern NH Health began collaborating around certain services with Mass General and created a clinical affiliation that allows the hospital to send patients to Mass General for care they might not be able to receive at Southern NH Health because it is highly specialized and there is not enough demand in the Greater Nashua market to employ that particular specialty. “We make arrangements with Mass General that has specialists on an as needed basis. That meets our local needs for that particular specialty,” Rose says.
Affiliations, such as Granite Health, are also popping up in the state. Granite Health is a partnership between Catholic Medical Center, Concord Hospital, Exeter Health Resources, LRGHealthcare, Southern NH Health, and Wentworth-Douglass Hospital that creates a health system where hospitals can share data, best practices and jointly purchase services.
Hospitals also created NH Accountable Care Partners ACO, which is a joint venture between five hospitals and ACO professionals. Based in Concord, ACO is a nonprofit consisting of more than 1,400 healthcare providers employed by Catholic Medical Center, Concord Hospital, Exeter Hospital, Mid-State Health Center, Riverbend Community Mental Health, Concord Regional Visiting Nursing Association, Elliot Health System, Southern NH Health System and Wentworth-Douglass Health System to coordinate the health care of more than 55,000 Medicare fee-for-service beneficiaries throughout the combined service areas.
The goal of these consolidations, affiliations and partnerships, Rose says, is to seek operational and administrative efficiencies, improved access to care and to leverage fixed-cost infrastructure like information technology.
Also, he adds, there are certain levels of care they can’t accommodate, such as organ transplants, for example. In those cases, he says, they work very closely with Mass General to make sure that care is coordinated and that they have quick access to those services when needed. “[After] that initial episode of care is provided, the follow-up care can be provided locally,” he says. “That’s about bringing specialty care to our market.”
Dartmouth-Hitchcock heads the largest system in the state, and “can’t absorb every critical access hospital in the state,” Conroy says. “We’re working with them to figure out how to keep their heads above water financially.” Dartmouth has its own network, the New England Alliance for Health and offers group purchasing and pharmacy purchasing to smaller hospitals to help keep their costs down. Conroy says smaller hospitals are looking to Dartmouth to provide telehealth and telemedicine services to help deliver care to their communities without having to officially partner.
Carucci says he thinks that consolidations and affiliations will not only continue, but will accelerate over the next 36 months. “A lot of these transactions are really new, so what that looks like in three years is really hard to predict,” he says. “What I do know is that it should allow best practices over a multitude of facilities and the ability to leverage the scale of a larger organization.”