New York City Council Oversight Hearing: Access to Specialty Care at New York City Health + Hospitals | NYC Health + Hospitals

New York City Council Oversight Hearing: Access to Specialty Care at New York City Health + Hospitals

Mitchell Katz, M.D., President and Chief Executive Officer
Monday, February 25, 2019

Access to Specialty Care at New York City Health + Hospitals

Good afternoon Chairwoman Rivera, and members of the Hospitals Committee. I am Mitchell Katz, M.D., President and Chief Executive Officer of the NYC Health + Hospitals (“Health + Hospitals”). Thank you for the opportunity to share Health + Hospitals progress in implementing one of our top priorities – improving access to needed specialty care. Joining me here today is Dr. Dave Chokshi, Health + Hospitals Chief Population Health Officer.

As you know, I am a primary care doctor and I am a strong believer in the value of primary care for keeping patients healthy. We’ve made great progress on access to primary care in recent months and patients can now see a primary care provider in our system within one to two weeks (some patients may wait longer if they wish to see a particular doctor in a particular clinic).

But as much as I believe in primary care, at times my patients need specialty care—something beyond what a primary care doctor can do. They may have severe congestive heart failure or a broken bone.

In serious cases, Health + Hospitals can ensure immediate access to specialty care. If you, for example, have an acute loss of vision and come to see me, I will get you to an ophthalmologist today. And the quality of the clinical care in our system is as high as any provider in the city. But when the need is less, but not an emergency—a patient with a severely arthritic joint, a patient with persistent gastrointestinal reflux, the waiting times can be much longer.

Part of the challenge is that reimbursement for uninsured persons needing outpatient specialty care is very limited and therefore a person without insurance in New York has few options for where they can receive specialty care at an affordable price. This is different than primary care and inpatient specialty care.

Federally Qualified Health Centers (FQHC) receive enhanced Medicaid payments and some federal grants to help them provide primary care to uninsured patients. As a result, FQHCs are able to offer those services broadly and uninsured patients can find primary care outside of Health + Hospitals. Similarly, for inpatient specialty care, private hospitals can receive revenue from the state and federal governments for caring for the uninsured. And so an uninsured patient coming in through the ED or needing inpatient care can often get seen at a private hospital.

But for outpatient specialty care, there is no state or federal revenue stream for health care providers. As a result, for a low income, uninsured person, it is very very difficult to get an outpatient specialty appointment at a private health care provider. And one of the reasons I love public health systems and that I am so proud to work at Health + Hospitals, is that we offer our outstanding specialty care to all New Yorkers, regardless of whether they have insurance. We are very proud of that mission and the care we provide, but it does pose specialty access challenges that are unique to Health + Hospitals.

Like many things in a large system like ours, there is a lot of variation in the wait times for different specialties at different hospitals. Again, while any urgent and certainly any emergent need for a specialty care is met right away, if you were a new patient trying to make an appointment for a subspecialty at one of our hospitals – say a consult with a neurologist or a rheumatologist – the wait could be several weeks. The balance we need to strike is how do we provide a good patient experience and connect people to the care they need, while making sure we’re not overloading our specialty clinics with patients who could be seen in primary care.

So how is Health + Hospitals working to strike that balance and get patients the right care at the right time in the right place? First, we’re using technology to speed up access to needed specialty care. Our expanding eConsult system lets primary care doctors like me send an electronic referral directly to a specialty clinic. I can include all the necessary clinical information, any scans or other images, and any information a specialist needs to provide an initial consult. My eConsult will then be reviewed by a clinical expert right away. If the specialist thinks I can handled the patient in primary care, they will share their guidance back with me, giving me suggestions such as a change of medicine If the specialist believes the patient needs to be seen, the patient will be contacted with an appointment.

Today, eConsult is live in over 100 clinics across 10 facilities, including adult medical and surgical subspecialties, behavioral health, and pediatric subspecialties.1 Nearly 8,000 referrals per month are managed by eConsult clinics, which is up from 2,300 per month in 29 clinics in January 2018. And our average review and respond time is under three days. For a set of 14 specialty clinics using eConsult, for over a year, we saw a 23% reduction in overall wait time for new patient visits.

Second, we need to continue to improve our scheduling systems and our referral practices to reduce no shows and limit overbooking. We are working with clinics across our system, our referral offices, and our appointment call center to standardize our scheduling templates and referral practices. Something as simple as making sure appointments slots are the right length can have a major impact on how long people wait to get in for an appointment. Similarly, making sure our referral offices, our emergency departments, and our call center can effectively schedule patients is critical. When a person leaves our emergency department with an appointment for a follow up visit, it needs to be a real, dedicated appointment, not just a direction to seek a walk in visit. Rolling out our unified EPIC electronic health record and referral and scheduling processes will be a big help in reducing no shows and wait times.

Third, we need to invest in new clinical services and providers that will help us meet demand for specialty care. In recent months we have approved business plans to invest in HIV care, gastrointestinal care, cardiac care, and several other areas. If we can address demand and reduce wait times by making smart investments, I want to do that.

Finally, while I have focused a lot on ways we are looking to improve access to specialty care, I don’t want to lose sight of the amazing specialty care we – and often we alone – provide to hundreds of thousands of New Yorkers each year. Health + Hospitals has an enormous range of specialty clinics that is unmatched across any public system in the country. For instance, at Metropolitan Hospital, we offer some gender affirming surgeries to transgender and non-conforming patients – making us the only public hospital in the nation that provides those services. From our unmatched behavioral health services, to infectious diseases, to care for the disabled or other underrepresented populations, our specialty care services are one of the many things that make me so proud to work at Health + Hospitals.

Thank you again for having me today, and Dr. Chokshi and I look forward to your questions.

Health + Hospitals’ Approach to Specialty Care

Below are some of the specialty care services that are offered at Health + Hospitals:

HIV Services: New York City has been a leader in fighting the HIV/AIDS epidemic for decades but in recent years some services at Health + Hospitals were shrinking – losing patients and missing a revenue opportunity for our system. NYC Health + Hospitals/Jacobi recently announced the Health & Empowerment Center, which is an expansion of a multi-service clinic that will expand access to comprehensive, state-of-the-art HIV treatment, education, and prevention services. With expanded staff and a one-stop service model to offer on-site nutrition counseling, mental health services, and more, the center will be able to serve an additional 100 patients annually, offer same-day appointments, and give the city’s public option health plan, MetroPlus, an opportunity to enroll more patients in its specially designed plan for patients with HIV. NYC Health + Hospitals is investing $1.1 million annually to cover additional staffing, including an additional full-time HIV specialist and two new nurses. The center is part of NYC Health + Hospitals’ comprehensive, multi-year redesign to build a competitive, sustainable organization that will continue to offer high-quality and accessible health care to the people of New York City.

Child & Adolescent Behavioral Health Services: Within the system, Bellevue, Elmhurst, Kings County, and Metropolitan hospitals provide the full continuum of acute and routine mental health services for children and adolescents, including a combined 134 inpatient psychiatric beds, and robust outpatient behavioral health services for youths, including: psychiatric evaluation, medication, individual, group, and family therapy. Follow-up mental health appointments are provided, as needed. Other specialty services included, but not limited to are:

  • Children’s Comprehensive Psychiatric Emergency Program (CPEP): Bellevue Hospital has the only dedicated Children’s CPEP in the State, which includes comprehensive psychiatric assessment and brief stabilization with six child and adolescent extended observation beds and a very busy Interim Crisis Clinic.
  • Partial Hospitalization Programs: At Elmhurst and Bellevue, patients receive mental health services five days per week for six weeks while attending hospital-based schools.
    Home-Based Crisis Intervention Units: At Elmhurst and Bellevue, patients at risk of inpatient hospitalization can be followed at home by staff 2-3 times per week for six to twelve weeks.
    “First Episode” Psychosis Program: Kings County has a combined adolescent and young adult inpatient unit to address the needs of youths who present with their “first episode” of psychosis. They are often at risk for dangerous behavior, including suicide attempts.
  • Mobile Crisis Units: At Elmhurst, Bellevue, Kings County, and Lincoln if hospital staff cannot contact the patient; a mobile crisis unit is sent to their home for follow-up.

Trauma-informed care: Over the next year, Health + Hospitals in collaboration with NYC Department of Health and Mental Hygiene, will model and begin implementation of a trauma-informed care system in several of our hospitals’ obstetrics department, as implemented by Trauma Transformed from the Bay Area in California. The goal of the program is to build the capacity of clinical providers to recognize and mitigate the impact of organizational trauma, implicit and explicit bias, and gender oppression on birth outcomes for women of color. Principles of a trauma-informed system include: 1) understanding trauma and stress; 2) safety and stability; 3) cultural humility and responsiveness; 4) compassion and dependability; 5) collaboration and empowerment; and 6) resiliency and recovery. Trauma can have a long-lasting and broad impact on lives that can create a feeling of hopelessness.

Access to care for disabled individuals: Health + Hospitals has worked with the Independence Care System (ICS) Women’s Health Program to conduct an environmental review to assess issues related to disabled individuals’ ability to obtain services in our facilities. Their recommendations included: 1) review of and modifications to operations policies and practices; 2) establishment of essential patient supports; 3) disability sensitivity and awareness training for clinical and non-clinical staff; 4) coordination of pre and post onsite care for
ICS members referred to the facility for Women’s Health Services; and 5) equipment that will facilitate health care for women with disabilities.

In 2014, the City Council provided $2.5 million in capital funding to update four facilities – Morrisania, Sydenham, Cumberland, and Woodhull. The projects are in various stages of implementation. The programmatic components are now being implemented at Lincoln, and Gouverneur. In FY19, the City Council awarded funding of $125,000 to ICS to support the Women’s Health Access program at ICS to continue its work with Health + Hospital to increase access to accessible/disability competent care to women with physical disabilities. We look forward to collaborating with ICS on this important work.

1 Bellevue, Coney Island, Harlem, Kings County, Jacobi, Lincoln, Woodhull, Metropolitan, North Central Bronx, and Elmhurst.