‘$50M a year’: What happens when health systems cover gaps no one else will

 As hospitals across Los Angeles County closed psychiatric beds over the past decade, the unmet need concentrated in fewer and fewer places. UCLA Health became one of them.

By the time Johnese Spisso, president of UCLA Health and CEO of the UCLA Hospital System, committed to building a 139-bed dedicated mental health campus in the Mid-Wilshire neighborhood, a $650 million project slated to open in January, her system was already running its existing neuropsychiatric hospital at 110% capacity and starting every day with patients boarding in emergency departments, waiting for psychiatric beds that didn’t exist.

That’s why the investment and subsequent operating loss will be worth it.

“We’ll probably lose about $50 million a year operating it,” Ms. Spisso said during a keynote interview at Becker’s CEO + CFO Roundtable. “But every day we have, we start the day with 15 to 20 site borders in our EDs just waiting for beds.”

The scale of the unmet need in Los Angeles County, by her account, makes the investment unavoidable. Roughly 65,000 people are unhoused on any given day in the county. Ms. Spisso said UCLA has been running a homeless healthcare collaborative for five years with mobile primary care clinics and a psychiatrist traveling to encampments, but inpatient psychiatric capacity has remained the more acute gap.

“We’re one of the most underbedded counties in the whole United States for mental health beds,” Ms. Spisso said. The new hospital, expected to open early next year, will help.

The logic running through the investment is a calculation of what happens when no one else steps in. At The Johns Hopkins Hospital in Baltimore, Redonda Miller, MD, president of the hospital, has been working through the same question from a different angle in a different city.

Several years ago, Hopkins partnered with Baltimore City on a housing wraparound program, renovating 300 homes as part of an 1115 Medicaid waiver and providing supportive services for high-utilizing patients who were homeless. The program produced results significant enough that the state took it over.

“30% decrease in ED visits for high utilizers,” Dr. Miller said. “And obviously the residents who were in these permanent homes loved it. So the state took it over.”

With that program now state-administered, Hopkins turned its attention to violence. The hospital’s violence interruption program deploys a team of violence interrupters, social workers, nurses and chaplains when teenagers and young adults arrive after a violent incident, initially for gunshot wounds, now for any violent act. The team provides counseling and continues following patients after discharge.

“In the last two years since we started the program, we’ve seen nearly 700 youth and young adults,” Dr. Miller said.

Hopkins is also working to intervene before young people reach the emergency department. Building on a school-based health center launched six or seven years ago at a local KIPP school in Baltimore, the hospital is expanding the model into three more inner-city schools, embedding nurse practitioners to provide asthma care, medication management and behavioral health support on-site.

“When you look at absenteeism from school, either from ADD or asthma flares, it plummeted,” Dr. Miller said.

Cristy Page, MD, MPH, CEO of Chapel Hill, N.C.-based UNC Health and dean of the UNC School of Medicine, is operating on a scale that stretches across an entire state.

“It’s shocking to see that your life expectancy is so tied to your zip code,” Dr. Page said. “Even when we track the counties one or two counties over, it might be a 10-year difference in life expectancy.”

North Carolina has one of the largest rural populations in the U.S. UNC Health has a physician in all 100 of the state’s counties and trains physicians through branch campuses and expanded rural residency programs. The most acute pressure point in rural communities is maternity care; obstetric units are typically the first service line to close when a small hospital comes under financial pressure.

Dr. Page’s team has spent several years working to restructure the model without closing units. In the critical access hospital she referenced, the drive time for expectant mothers was cut from 90 minutes to under 45.

“We really set out to prove something different, that if you do it thoughtfully, that you can change the model and do it in a way that actually helps sustain the hospital, sustain the deliveries and make those deliveries with less of a drive,” Dr. Page said.

The broader sustainability challenge in rural North Carolina goes beyond keeping individual units open to rearchitecting care delivery across communities, concentrating specialty resources across a region rather than duplicating them in adjacent hospitals competing for the same thin patient volumes.

“There’s not enough people there to support sometimes two hospitals in a county that duel and fight with one another across the river,” Dr. Page said. “So we are coming up with new ways of approaching that to right size, some of what’s needed in the counties, but also to ensure that we’re elevating the quality.”

https://www.beckershospitalreview.com/hospital-management-administration/50m-a-year-what-happens-when-health-systems-cover-gaps-no-one-else-will/