COMMUNITY SERVICES PLAN 2009

Comes out every September

I. Mission Statement

Catskill Regional Medical Center’s Board of Directors updated its Mission Statement during the past year following a comprehensive planning process incorporating input and feedback from the Board of Directors, CRMC Senior Management as well as executives affiliated with the General Hudson Valley Health System. Catskill Regional Medical Center’s Mission Statement was simplified to make it more relevant and easily understood by key stakeholders including: 1. Sullivan County consumers/patients; 2. CRMC staff; as well as other; 3. Sullivan County Health and Human Service agencies and providers with which we work closely in coordinating services. CRMC’s updated Mission Statement to “Improve the health of our community by providing exceptional health care” has been disseminated on the hospital’s web page. Catskill Regional Medical Center’s vision was also recently updated and revised to affirm “Catskill Regional Medical Center will be the best community hospital in New York State by providing outstanding service to all.” Catskill Regional Medical Center’s values reflect our updated Mission and Vision by focusing specifically on Care and Compassion, Safety and Privacy, Respect and Integrity as well as Quality and Innovation.

II. Service Area

Catskill Regional Medical Center’s service area for community/local health planning includes all fifteen townships within rural Sullivan County, New York. CRMC has been designated by both the New York State Health Department and federal CMS as both a sole community provider and a rural referral center. CRMC with divisions in both Harris and Callicoon is the sole acute care hospital serving Sullivan County. The Medical Center has been and will continue to be an active partner with Sullivan County Public Health Services towards evaluating and enhancing community health status.

The Hospital’s service area within Sullivan County is into primary and secondary service areas. The primary service areas are those Sullivan County townships and zip codes which are either closer to CRMC than any other hospital facility or where CRMC has a predominant market share. Specifically, the Sullivan County townships in the primary service area are Bethel, Callicoon, Cochecton, Delaware, Fallsburg, Forestburgh, Fremont, Liberty, Neversink, Rockland, Thompson and Tusten. The primary service area zip codes are: 12701, 12720, 12723-12727, 12733-12736, 12738, 12740-12742, 12745, 12747-12754, 12758-12766, 12768, 12775-12779, 12782-12784, 12786-12789 and 12791.

The three remaining townships of Highland, Lumberland and Mamakating within southeastern Sullivan County constitute CRMC’s secondary service areas. These three townships represent approximately 19% of Sullivan County’s overall 76,500 population. The secondary service area zip codes include: 12719, 12721, 12722, 12732, 12737, 12743, 12769, 12770, 12781, 12785, 12790 and 12792.

The following demographics characterize Sullivan County’s rural service area:
1. Extensive and growing geriatric population; 2. Higher proportions of black and Hispanic populations when compared with most upstate New York rural communities; 3. Villages of Monticello and Liberty surrounded by geographically dispersed rural populations; 4. Economic base predominately comprised of agriculture as well as services focusing upon health care, tourism, government and education and; 5. Extensive medically indigent population with high proportion of individuals either on Medicaid or totally lacking health insurance coverage.

III. Public Participation

Catskill Regional Medical Center recognizes that broad-based public participation constitutes an integral component in the preparation of an updated Community Services Plan that is responsive to the health needs of the Sullivan County community. A community needs assessment was conducted collaboratively with Sullivan County Public Health Services, the local health department. Public participation was sought through a multitude of vehicles including: 1. Four Community Health Forums conducted in conjunction with Sullivan County Public Health Services. These forums were held at different locales and times throughout Sullivan County to increase the likelihood of attendance by a broad cross-section of the community. The forums were conducted in accordance with the timeline delineated below and included an evening program to attract the working population, a meeting in Callicoon, NY accessible to western Sullivan County consumers, as well as separate meetings in the more populous villages of Monticello and Liberty.

The four Sullivan County health forums were publicized by placing information flyers in local post offices, newspaper stories in three local newspapers, radio announcements on several Sullivan County radio stations, as well as news coverage on Cable Television Channel 6. Unfortunately, despite this extensive publicity, only a few individuals attended 3 of the 4 programs, curtailing broad-based input. The Liberty program which immediately followed a Senior Citizen luncheon meeting was very well attended with between 30 and 40 active participants. The summary of the community health care findings and recommendations from each forum follows.

SULLIVAN COUNTY COMMUNITY HEALTH FORUMS

1. CALLICOON – 4 PARTICIPANTS – JULY 30, 2009
   HEALTH CARE PRIORITIES
1. Enhanced access to Primary Care & Eye Care Medical Services including evening and weekend hours within Sullivan County rural communities.
2. Expanded Chronic Care Disease Treatment & Management Services.
3. Improved Transportation Services.
4. Need for Outpatient Mental Health Services within Western Sullivan County.
5. Additional Medical Day Care Programs.
6. Planning for Health Care Resulting from the Impact from Drilling for Gas.
2. MONTICELLO - 0 PARTICIPANTS – AUGUST 5, 2009
3. HARRIS - CRMC - 3 PARTICIPANTS – AUGUST 6, 2009 (EVENING)
   HEALTH CARE PRIORITIES
1. Improved transportation services to health care providers.
2. Enhanced affordable health care services.
3. Respite program for caregivers.
4. Need for local dental surgical services for Sullivan County’s developmentally disabled population.
5. Geriatric Case Management services.
6. Expanded elderly health care services including chronic disease program services.
7. Need to inform consumers about existing community health providers resources and services.
4. LIBERTY SENIOR CITIZEN CENTER – APPROX. 30 TO 40 PARTICIPANTS - AUGUST 7, 2009
1. High cost issues of Medicare and supplemental health insurance programs for elderly.
2. Need detailed information for elderly consumers re: selecting Medicare Part D pharmaceutical health insurance coverage.
3. Continue Healthmobile services.
4. Need for Sullivan County obesity reduction programs.
5. Transportation to health care program and provider services for elderly and poor.
6. Assisted Senior Housing living with health care supportive services.
7. Expanded elderly health care program services for chronic diseases like diabetes.
8. Improved community outpatient mental health and E/R psychiatric services.

The Sullivan County Health Department joined the six remaining Hudson Valley regional counties to conduct a consumer health survey funded through a HEAL 9 project grant. Preliminary survey results for the Sullivan County consumers were recently received. There were 280 respondents to the community surveys with a low percentage of both males and the elderly responding. Several preliminary findings identified additional community health needs including: 1. High Sullivan County prevalence rates for obesity; 2. Difficulty affording dental care treatment services; 3. Significant need for diabetes and cardiovascular heart disease services; 4. Falls prevention programs and; 5. Need for additional preventative health screening and educational program services.

CRMC assisted the Sullivan County Public Health Department who jointly contracted with New York Medical College to carry out a regional needs assessment survey of health care providers in the County. The Hospital participated by requesting Department Heads as well as members of Senior Management to complete and return the provider survey questionnaire. Furthermore, CRMC also forwarded the provider survey by e-mail to its current complement of over 200 Sullivan County medical staff members. Unfortunately, the health care provider results were not tabulated and compiled in a timely enough fashion for incorporation within CRMC’s updated 2009 Community Services Plan. However, we will review the provider findings upon availability and update the Community Services Plan priorities as warranted.

In addition, Catskill Regional Medical Center received health care provider input and feedback from members of the Sullivan County Rural Health Network. This Network is comprised of approximately one dozen local health and human service organizations including administrative representatives from both the Seelig and Grover Hermann Hospital divisions of CRMC. The Sullivan County Rural Health Network adopted three local health care priorities including: 1. Access to health care services; 2. Maternal and Child health issues; and 3. Behavioral and substance abuse issues.

Steven Ruwoldt, CRMC Chief Executive Officer, established a multidisciplinary Community Advisory Board during the fall of 2007. The CRMC Community Advisory Board is comprised of 33 consumer and provider representatives who meet quarterly to provide feedback on hospital performance, as well as to provide input on Sullivan County community health needs, issues and priorities. The Hospital Advisory Board identified Chronic Diseases including Diabetes and Cardiovascular prevention, care, and treatment, as well as behavioral health issues including mental health and substance abuse, as the highest priority, unmet health care needs throughout Sullivan County.

CRMC’s Senior Management recently reviewed updated, Sullivan County health status reports regarding identifying, developing and implementing a three year action plan. Specific documents reviewed for developing priorities include: 1. New York State Prevention Quality Indicators; 2. Updated Sullivan County Health Indicators Profiles (2003-2007) and; 3. 2010 National and NYS prevention priority goals and objectives including applicable sections of Healthy People 2010. The most significant identified Sullivan County community health status disparities include: 1. High age adjusted prevalence rates for several chronic diseases; 2. Pattern of unusually high mortality rates from both suicide and cirrhosis of liver within recent years; 3. Excessive mortality from unintentional injuries from both motor vehicles and other factors including falls; 4. High inpatient hospital admissions for ambulatory care sensitive conditions reflecting that the majority of Sullivan County townships are currently designated as both primary care health professional shortage areas as well as medically underserved populations and; 5. Lower rates of minority and medically indigent women procuring first trimester prenatal care services.

IV. ASSESSMENT OF PUBLIC HEALTH PRIORITIES

Catskill Regional Medical Center utilized the broad based input received at four community health care forums, Sullivan County consumer survey findings, Sullivan County Rural Health Network feedback as well as recommendations from the Hospital Community Advisory Board to preliminarily select several health prevention priorities. CRMC’s preliminary priorities were then reviewed by CRMC Senior Management executives with the Greater Hudson Valley Health System, the Sullivan County Health Department as well as other community partners. Updated Sullivan County health indicators focusing on community health status including mortality and morbidity as well as accessibility barriers, were closely evaluated by members of Senior Management in an effort to select several critical public health prevention priority agendas for implementation.

In order to measurably improve community health status by 2013, CRMC, working closely with key Sullivan County Community health stakeholders, have adopted three prevention agenda items for Sullivan County. Chronic Disease is the first Sullivan County priority. Selection of chronic diseases was predicated upon several factors including specifically: 1. Its identification as a major community need within several community forums; 2. Recommendation by Hospital Community Advisory Board members that chronic diseases should be selected as a countrywide health priority initiative; 3. Sullivan County’s extensive and growing geriatric population manifesting high prevalence rates for diabetes, coronary heart disease, congestive heart failure, cardiovascular disease and cancer; 4. High hospital inpatient admission rates at both the Seelig and Grover Hermann Hospital divisions for chronic diseases and; 5. Sullivan County Health Indicator Profiles (2003-2007) substantiating high mortality rates for several chronic diseases.

The Chronic Disease community objectives posed by CRMC will focus upon achieving three objectives by the year 2013 in Sullivan County : 1. Reducing the prevalence of adult diabetes and hospital complications of diabetes; 2. Decreasing the age-adjusted coronary heart disease hospitalization rate and; 3. Reducing the congestive heart failure hospitalization rate among adults.

The Hospital has selected Mental Health and Substance Abuse as the second health prevention focus. Mental Health and Substance Abuse were selected as a high public community health priority initiative in Sullivan County because of several factors including: 1. Consistency with Sullivan County Rural Health Network priority; 2. Excessive mortality rates during timeframe 2003-2007 from both suicide and cirrhosis of the liver; 3. Identification of unmet need for additional mental health services within western Sullivan County outlying communities as well as forums; 4. Strong recommendation by the Hospital Advisory Committee that mental health and substance abuse should be selected as a County Community Public Health initiative.

Catskill Regional Medical Center’s Mental Health/Substance Abuse Sullivan County objectives will focus upon: 1. Substantially reducing the excessive age adjusted suicide mortality rate; 2. Decreasing significantly the age adjusted alcohol and substance abuse hospital inpatient admission rates by 2013 as well as; 3. Reducing the percentage of adult reporting greater than 14 days with poor mental health status to no more than 7.8%.

The Hospital selected Access to Quality Healthcare as the third project for the multidisciplinary Sullivan County Prevention agenda. Access to Quality Healthcare was selected based on several considerations including: 1. Consumer feedback at each community forum; 2. NYS DOH Prevention Quality Indicator’s data substantiating large number of Sullivan County hospital inpatient admissions for ambulatory care sensitive conditions; 3. Priority selection by Sullivan County Rural Health Network Members; 4. Preliminary results and findings from the Consumer community health needs assessment survey questionnaire, documenting needs for additional, accessible primary medical care and dental services; and 5. Documentation of nine rural western and northern Sullivan County communities as both primary care health professional shortage area, as well as medically underserved populations.

CRMC will work closely with Sullivan County Public Health Services and other community health organizations to enhance accessibility to quality health care services. Together they will address this goal by focusing on these three objectives throughout Sullivan County: 1. Expanding the percentage of adult residents who have a regular health care provider; 2. Increasing the percentage of cancer cases diagnosed at early disease stage; and 3. Decreasing substantially from current baseline level of 19%, the proportion of adult residents lacking health insurance coverage.

V. CATSKILL REGIONAL MEDICAL CENTER COMMUNITY SERVICE ACTION IMPLMENTATION PLAN 2010-2012

Catskill Regional Medical Center has prepared a three year Community Services Action Implementation Plan for 2010-2012. The Action Implementation Plan will focus specifically on long-range solutions to improve the community health status of Sullivan County. The Plan utilizes the limited available resources to collaboratively implement cost-effective proposals for these public health priority areas. Specifically, the Plan focuses on: 1. Chronic Disease; 2. Mental Health and Substance Abuse and; 3. Access to Quality Healthcare.

CRMC is a NYSDOH designated financially distressed hospital because of the Hospital’s high proportion of medically indigent patients. This high proportion of medically indigent patients results in large amounts of bad debt and charity care and limited discretionary financial working capital for community public health initiatives. Therefore, the ability to collaboratively resolve these critical Sullivan County community public health initiatives will be conditional and largely predicated upon procuring additional financial resources. Furthermore, the active participation and ongoing support by both Sullivan County Public Health Services as well as other key community health and human service agency stakeholders will be essential for the successful resolution of these issues.

Catskill Regional Medical Center will expand its current chronic disease initiatives. Plans are being developed to expand the multidisciplinary Diabetes and Wound Care Center. CRMC is investigating the community need and financial viability of implementing a state of the art hyperbaric oxygen therapy program for Wound Care. In addition, CRMC will be seeking NYS DOH grants to expand community-oriented primary and secondary diabetic educational initiatives targeted at high risk population groups. Using a federal Small Health Care Provider Improvement Grant, CRMC established an integrated Chronic Care Disease Management initiative focusing specifically on Diabetes and Cardiovascular disease. The electronic patient registry disease tracking software has the capacity to be expanded to encompass all of Sullivan County.

Catskill Regional Medical Center has selected Mental Health and Substance Abuse as the second component of the three year County community public health prevention agenda. The plan will involve expanding the psychiatric social worker capability in the Seelig Hospital Division emergency room, assuming that sufficient grant funding is available. CRMC is planning on coordinating psychiatric social worker services with the Sullivan County Department of Community Mental Health System. The expansion of on-site emergency psychiatric social worker services will enhance continuity of care, while achieving the objective of decreasing preventable hospital admissions for behavioral health care issues with psychiatric, alcohol, substance abuse or dual diagnosis clinical manifestations.

According to the updated 2003-2007 County Health Indicator Profile, Sullivan County has a statistically high age adjusted suicide mortality rate. The health services literature has indicated that community wide gatekeeper intervention programs have significantly decreased suicide mortality rates within several rural communities. The gatekeeper programs have focused on training: 1. Clergymen; 2. Bartenders; 3. Beauticians; 4. Office on Aging personnel; and 5. Teachers to help identify and refer potentially high risk patients outside the traditional care networks for mental health services evaluation, counseling and intervention if clinically required. Additional financial resources will be required to implement this community initiative.

Catskill Regional Medical Center has been actively exploring behavioral health collaborative initiatives with the Recovery Center and Sullivan County Department of Community Services. The behavioral health collaboratives will be specifically designed to accomplish several significant community mental health objectives including 1) enhancing community-based outpatient alternatives to inpatient hospitalization for psychiatric and substance abuse problems; 2) decreasing Sullivan County’s high prevalence rates among high risk target populations for both behavioral health as well as alcohol and substance abuse patient clinical manifestations; and 3) developing a healthy community reflective of Healthy People 2010 objectives. The long term objective is to collaboratively implement a cost effective integrated behavioral health care delivery system throughout Sullivan County.

Catskill Regional Medical Center has selected access to Quality Healthcare as the final component for the three year priority intervention plan. CRMC has already begun working towards enhancing accessibility to primary care medical services within medically underserved rural communities. The Hospital will be seeking additional start-up financial assistance from the Sullivan County Rural Health Network and from the New York State Health Department to expand initiatives for other medically underserved rural Sullivan County communities within rural western and northern townships. Specifically, the focus will be on developing an integrated primary care medical clinic with electronic medical record capability for physicians and nurse practitioners within the designated H.P.S.A. and medically underserved communities of Livingston Manor, Narrowsburg, Roscoe, Callicoon, Wurtsboro and Grahamsville.

Sullivan County has a substantial population of adults (19%) without health insurance coverage. This group is another population within the County whose limited coverage negatively impacts financial accessibility. CRMC will continue to make available at no cost information on facilitated health insurance enrollment through Maternal Infant Services Network of Orange, Sullivan and Ulster counties within the Hospital facilities. Financial accessibility issues are also exacerbated by an inadequate public transportation infrastructure, as noted in several community forums. CRMC will participate collaboratively with other Sullivan County health and human service agencies to advocate for enhanced coordinated rural transportation services. Catskill will continue to actively participate with HANYS and the American Hospital Association to advocate for responsible federal and NYS proposals to ensure broad-based, affordable health insurance coverage within a rational health care system. Moreover, CRMC will work closely with Sullivan County Public Health Services, Monticello Community Health Center and Prasad to expand affordable and accessible dental prevention and treatment services throughout the County.

VI. FINANCIAL AID PROGRAM

Catskill Regional Medical Center’s Board of Directors has adopted a comprehensive Financial Assistance Policy to assist medically indigent individuals with a limited ability to pay or who lack health insurance coverage. The key parameters of CRMC’s Financial Aid policy are:

1. Priority is given to patients who fail to meet the eligibility criteria for Medicare, Medicaid or any applicable government, financial assistance policy. This policy was adopted to ensure that charitable care services are provided first to those patients without available health insurance coverage.
2. All patients lacking health insurance coverage will receive a substantial discount (50%) from current Hospital changes. This policy, consistent with both AHA and HANYS recommendations, is designed to ensure that patients without health insurance pay fees closer to Federal Medicare reimbursement rates.
3. Furthermore, patient with limited financial assets and household income (lower than 300% of the current Sullivan County prevailing poverty level) will be eligible for additional discount based on income in accordance with our sliding fee schedule.
4. The CRMC Board of Directors has established a Financial Assistance Advisory Committee to assess and evaluate how well the Financial Assistance Policy is working, to recommend process improvements, as well as to consider the special circumstances of individual patients.
5. Primary and secondary service area zip codes for eligibility were based on Sullivan County demographics coupled with updated CRMC demographics. The primary and secondary service areas encompass all fifteen Sullivan County townships, as well as adjacent communities in Wayne County, Pennsylvania and Ellenville within southwestern Sullivan County where CRMC receives significant number of inpatients for medical and surgical specialty services.
6. An installment plan has been developed and implemented to enable hospital patients to minimize the short-term financial impact from hospital payments.

Catskill Regional Medical Center’s Board of Directors will periodically review and update the Financial Assistance Policy and Guidelines on an ongoing basis. The Hospital anticipates that the declining economy and rising number of uninsured Sullivan County residents will substantially increase CRMC’s bad debt, as well as its charitable care requirements. CRMC’s 2008 certified financial statements, prepared by KPMG, show substantial charitable care contributions as well as bad debts, each surpassing several million dollars. The Hospital’s commitment to meet the ongoing substantive charity care contributions and additional bad debts substantiates CRMC’s compliance with its mission and its willingness to serve all clinically appropriate patients including Sullivan County’s medically indigent lacking health insurance coverage.

VII. CHANGES IMPACTING COMMUNITY HEALTH/PROVISION OF CHARITY CARE/ACCESS TO SERVICES

Catskill Regional Medical Center has identified two significant changes that are likely to impact the care of members of the Sullivan County community. The first change anticipated should be highly favorable for both operational improvement and community health care. CRMC has recently received final New York State Health Department’s authorization to merge and become an active member of the Greater Hudson Valley Health System.

Catskill Regional Medical Center’s active participation within the Greater Hudson Valley Health System will generate several, substantial health care advantages for Sullivan County residents including specifically:

1. Enhanced accessibility to medical and surgical specialty services presently unavailable;
2. Clinical best-practice benchmarking opportunity to further improve hospital quality of services and generate operational economies of scale;
3. Facilitating enhanced coordination of hospitalization services;
4. Accessibility to broad range of specialized administrative and financial expertise; and
5. Capability of developing an integrated regional health care delivery system including implementation of the electronic medical record.

However, the second major development impacting Catskill Regional Medical Center could substantially diminish accessibility to high caliber medical services for medically underserved Sullivan County residents. New York State during the 2009 budget process diverted the vast majority of federal economic stimulus health care funding away from its intended purposes towards other less critical purposes. This development has resulted in substantial cutbacks to CRMC Medicaid reimbursement, starting December 1, 2009. The projected Medicaid negative financial impact is compounded by the economically depressed Sullivan County community with a high proportion of residents with either Medicaid coverage or who are medically indigent lacking any health insurance coverage. The Medicaid hospital reductions will be exacerbated by recent federal legislation proposing to also substantially decrease Medicare funding for hospitals.

It is critical to recognize that substantial decreases to Medicaid and Medicare funding for NYS hospitals including Catskill Regional Medical Center will have detrimental impacts on all patients, not just elderly and low income individuals. The financial cutbacks will seriously impact negatively on CRMC’s future capability of providing continued state-of-the-art medicine including purchasing new medical technology as needed. Moreover, the financial reimbursement cutbacks will preclude CRMC from having sufficient financial resources to fulfill many of the critical Sullivan County community health initiatives and priorities identified within our 2009 Community Services Plan. CRMC will be working closely with community residents throughout Sullivan County to explain the serious implications from Medicaid and Medicare reimbursement cutbacks of such a large magnitude. Furthermore, CRMC will continue to work collaboratively with both the Sullivan County Health Department as well as local health and human service agencies to identify discretionary financial resources to resolve identified community public health priorities.

Catskill Regional Medical Center, as an integrated component of our mission, places a high priority on fulfilling community health needs and priorities in the area of health promotion, disease prevention and community health education. We have continued our expansion of community sites. Nearly 10,000 individuals were provided health promotion program services recently at several hundred separate programs.

There was also increased activity in diabetes programs including: 42 community educational programs during 2008, outreach meetings of the Diabetes Support Group, a lobby display, glucose screenings at the Diabetes Center Expo in Monticello and continued leadership of the Mid-Hudson Catskill Regional Diabetes Coalition.

Once again, our volunteers gave over 24,000 hours of service in the hospital and Skilled Nursing Unit. During 2008, there were a total of 1,059 volunteers at CRMC. The volunteer hours donated to CRMC constituted an in-kind matching contribution surpassing $400,000 illustrating broad-based community support for Catskill Regional Medical Center.

In addition to hospital sponsored programs, projects and activities, the culture attracts or fosters individual community leadership and service in community civic, political, educational and social welfare organizations promoting literacy, reducing child abuse and family violence, promoting participation in ambulance corps, economic development and beautification, and other efforts contributing to building a healthy community. Although difficult to financially objectively quantify the broad-based and comprehensive nature of the services clearly substantiates Catskill Regional Medical Center’s ongoing commitment to fulfilling our mission of providing needed community health services. The Hospital, in response to Sullivan County community needs, provides a broad-based scope of health education, disease prevention and community support groups.

VIII. DISSEMINATION OF COMMUNITY SERVICES PLAN TO PUBLIC

Catskill Regional Medical Center will undertake to widely distribute the 2009 Community Services Plan. Copies of CRMC’s updated Community Services Plan will go to:

1. Local newspapers for distribution;
2. Sullivan County community public libraries; and
3. CRMC’s Health Information Library which is widely utilized by both patients and Sullivan County residents.

Furthermore, Catskill Regional Medical Center will post an updated copy of the 2009 Community Services Plan on the Hospital’s web page.