REPORT TO THE BOARD OF DIRECTORS – April 2020 | NYC Health + Hospitals

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REPORT TO THE BOARD OF DIRECTORS – April 2020

Mitchell H. Katz, MD
NYC HEALTH + HOSPITALS
PRESIDENT AND CHIEF EXECUTIVE OFFICER
REPORT TO THE BOARD OF DIRECTORS
April 30, 2020

CORONAVIRUS UPDATE

We are so proud of how well the healthcare heroes across NYC Health + Hospitals performed. While the health care systems in Wuhan, China and in parts of Italy collapsed, we did not, even though our public hospital infrastructure is aged, our resources are limited compared to some private hospital systems, and the needs of our patients, even in non-COVID times, is great due to the effects of living in poverty, institutional racism, poor nourishment, chronic stress, and higher prevalence of chronic disease. Not only did we meet the challenge of patients coming to us, but we were able to accept transfers from several independent hospital systems that became overwhelmed at a moment in time.

Support for Our Health Care Heroes

Our Behavioral Health and 18 Helping Healers Heal teams across the system have teamed up to provide emotional and psychological support to our 42,000 staff through a hotline, wellness rounds, 26 respite/wellness rooms within the facilities, 1:1 and group debriefs, and connecting staff to other immediate mental health resources where indicated. We know that none of us will be the same after going through this crisis but leaning on each other will help us heal and come out stronger on the other side of this pandemic.

Under the leadership of Dr. Eric Wei, we organized a fundraising operation like no other in the recent history of our public health care system. We have experienced an outpouring of support from the local, national and global communities to support our healthcare heroes. We have received more than $10 million in cash donations and over $10 million more from in-kind donations to lighten the load for our frontline staff responding to the COVID-19 crisis. This includes sending meals and food trucks to the facilities and providing transportation, grab and go groceries, relax packs, Girl Scout cookies and much more.

Our Communications and Marketing team has been touting the amazing work of our staff with a series of Health Care Heroes profiles that have been featured in our internal employee newsletter, the public website and on social media. They were able to secure a very special photo documentary tribute in The New York Times Magazine. And now are working on a unique multi-platform storytelling project featuring written testimonials, photos, video, statistics and audio podcasts to document the behind the scenes stories of preparedness and response, as well as the stories of bravery and compassion from the frontlines.

Status of Long-Term Care/Nursing Homes

The COVID-19 pandemic has caused extreme challenges to facilities for the elderly and most frail across the state and the country. Fortunately, our five public nursing homes in the NYC Health + Hospitals system are holding their own and are stable. Our post-acute providers haven’t been excluded from the negative effects of the crisis. However, we have lessened their impact by leveraging the shared resources of our integrated system: staff, supplies, clinical leadership, expertise and technology. This has allowed our facilities to control the spread of COVID through a secure supply of personal protective equipment (PPE) and skilled infection control staff. In fact, each post-acute care facility in our health system has 1-2 Infection Control certified nurses. They work closely with the Chief Medical Officers and Infection control physicians in our post-acute and acute care facilities. They oversee all infection control practices, train our workforce, and coordinate training and implementation of infection control quality improvement projects. We’ve never had to compromise on quality and compassionate care for our residents and their families.

All post-acute sites are following PPE guidelines and continue to follow State Department of Health (DOH) guidance for treating symptomatic patients who are suspected to have the virus. They monitor all staff entering our sites and do not allow visitors, per these mandates. However, they continue to focus on connecting patients and families via phone, FaceTime and other technology, and letters. It is our priority to keep families connected and engaged, even if they cannot visit in-person.

In addition to keeping staff and residents safe throughout this crisis, our nursing homes have also played an important role in helping our hard-hit hospitals. Each post-acute facility has expanded their bed capacity to help COVID-19 patient surge. We opened two wings at NYC Health + Hospitals/Carter to take patients requiring vent care. They have a great program to help patients wean off ventilators. We also opened additional beds at NYC Health + Hospitals/Coler and plan to open more beds at NYC Health + Hospitals/Gouverneur. Post-Acute Central Admission extended their hours to 7 days a week to admit patients from our hospitals 24/7 days a week.

Staff, Supplies and Equipment

Under the leadership of Dr. Natalia Cineas, Dr. Ted Long, Maureen McClusky, Danielle Dibari and Yvette Villanueva, we have partnered with over 30 additional staffing agencies to bring on board needed temporary/supplemental staffing, including 4,000 nurses, 500 providers (doctors, physician assistants, nurse practitioners), 250 environmental health workers (housekeeping) and 200+ other ancillary personnel such as respiratory therapists and pharmacists.

We have found it critically important to maintain ongoing communications with our workforce on PPE. Our facility CEOs and their executive teams have taken the lead to do so, working in concert with our Central Office leadership team. To counter any confusion borne of conflicting press and social media reports, NYC Health + Hospitals has published guidelines for PPE use that have been widely distributed and posted at the facilities for easy reference.

This communication helps advance the diligent work our supply chain team has done to keep our health care heroes safe and properly equipped, under the leadership of Dr. Danielle Dibari and in constant partnership with our facility leaders.

Though we placed orders in January to properly safeguard against any potential crisis, most manufacturers and distributers were unprepared for a huge increase in demand and thus placed our health system and all consumers on delayed deliveries. To navigate this shortage, we had to creatively source products from non-traditional or non-contracted vendors by talking with colleagues, placing cold calls, and following leads on potential sources, all while prioritizing product quality and safety. We placed 300 emergency purchase orders to these vendors and will continue to protect our supply and our staff vigilantly.

Anticipating that the traditional Supply Chain processes will not right themselves anytime soon and that demand levels will remain high, we have secured an external warehouse that has proved very beneficial to receive and catalog our needed supplies. Our team remains focused not just on PPE but also on associated supplies that have been in greater demand for ventilators, dialysis machines, catheters, laboratory supplies and other procedures. As we move into the next potential phase of a pandemic, we will continue to work closely with our clinical leadership and business partners to assess adequacy. Crucially, we will also continue to work closely with our facility-based Materials/Inventory Management Teams, a vital link that experienced severe pressure based on increase demand and staff losses due to the pandemic, for a further enhanced partnership.

Ambulatory Care/Testing

Our Gotham Health community health centers and hospital ambulatory care departments have continued to see patients throughout COVID. We have completed more than 60,000 televisits since the beginning of COVID, and have walk-in assessment and testing at many of our sites. We have also continued to accept new patients, through having initial visits through televisits with the ability to address any urgent issues that new patients might have.

NYC Health + Hospitals is also serving on the front lines of the City’s pandemic suppression and reopening efforts, setting up testing centers in a variety of high need communities. As of April 29, we have added 11 new testing sites associated with our Gotham clinics and acute care facilities across all 5 boroughs, including 3 new locations opened today in NYCHA facilities. We are working collaboratively with the Mayor’s office to acquire testing supplies, and we have had adequate personnel to complete more than 100 tests per day in our sites.

This week we also rolled out staff testing using new COVID-19 antibody tests to assess for prior exposure to COVID-19. We are focusing first on staff that have worked in high risk areas.

Long-term Planning

In recent weeks, system leaders have been able to dedicate more attention to medium and long-range planning for the system. The overriding priorities are to learn from our successes and challenges in this crisis, to play a meaningful role in the broader public health and social service responses to this crisis, and to prepare for future surges of patients. Key strategic efforts include:

  • providing the highest quality care for long-term COVID-19 patients,
  • safely open spaces in our facilities for non-COVID-19 patients and preparing to treat more patients with telehealth,
  • offering the new rehabilitation and other ambulatory care services that individuals recovering from COVID-19 will require
  • expanding our testing capacity and our ability to help monitor and care for individuals who test positive and need to isolate
  • helping address the anticipated health and social needs of patients harmed by the major economic challenges expected in the months ahead

Clinical and physical infrastructure master planning efforts are also under way. Led by Christine Flaherty, SVP of Facilities and Real Estate, Milton Nunez CEO of Lincoln Hospital, and Maureen McClusky SVP of Post-Acute Care, facilities are reviewing the changes to physical infrastructure during the crisis and other lessons learned from the major ramp up in ICU capacity and other changes in hospital operations.

Led by Dr. Machelle Allen, leadership across clinical disciplines – intensive care, pulmonary care, ambulatory care, and behavioral health among others – are reviewing clinical evidence to plan for future staffing, clinical services and protocols.

John Ulberg, SVP and CFO, Deborah Brown SVP of External and Regulatory Affairs, and Matt Siegler SVP of Managed Care and Patient Growth are evaluating the strategic and financial implications of recent policy changes and broader economic trends.

While the epidemiological modeling is highly uncertain, we are preparing for additional surges of patients in the future. We expect those surges will be driven by potential seasonality of the virus, the fall/winter flu season, and changes in social distancing guidelines. The scale of the system’s surge of ICU and medical surgical beds was enormous. Preparing to replicate that expansion more efficiently and effectively in the future will be a guiding principle of our planning.

Field Hospitals and Hospitals Capacity

All NYC Health + Hospitals facilities began preparing for a surge in patients in respiratory distress in January and February. This included using non-traditional hospital space as medical surgical, ICU and observation beds. Following the Governor’s directive in late March, facilities provided specific plans to increase total bed capacity by at least 50%, our system creatively added beds both within our facilities and in new surge spaces. Within our acute-care facilities alone, we had over 1500 ICU level beds for use, from a starting point of 320 certified ICU beds. In addition to increasing capacity, we transferred resources and patients across our system as patient volume increased at key facilities and subsequently at key receiving facilities as internal transfer volume increased. Among the most notable ICU-level capacity increases were Lincoln Hospital increasing from 80 to 250; Kings County from 40 to 165; and Bellevue from 70 to 270.

To protect our staff and assure quality patient care, Eric Wei’s group did almost 600 patient transfers from one of our hospitals to another. Bellevue also took in 349 internal transfer patients, the most of any facility in our system. Impressively, the second largest transfer destination was North Central Bronx which accepted 158 transfer patients and is in the process of adding 150 new ICU beds alone. Some hospitals both received transfers and then later needed help. For example, COVID-19 came later to Brooklyn so Coney Island and Woodhull received transfers and then later needed help from their sister hospitals.

The most impactful new hospital capacity that came on-line was Roosevelt Island Medical Center (RIMC) in unused space on the campus of Coler. RIMC was stood up in three weeks with a capacity of 350 beds and its current census is 180. RIMC will continue to serve as an important resource throughout the next phases of this epidemic. Other facilities like the Javits Center and the UNS Comfort took in fewer of our patients and the federal and state governments are likely winding operations down in the coming weeks and months. NYC Health + Hospitals and contractor SLS stood up 470 beds at Billy Jean King tennis center in a two-week period. Thankfully, that capacity was largely not necessary as the census has stayed below 50 patients. SLS has been an excellent partner in re-deploying clinical staff to our public hospitals. We are evaluating the utility of these sites in this post-surge period. We also secured 1,000 hotel rooms for patients post discharge from the hospital or otherwise needing isolation. The hotel census has been low thus far but we are taking steps to increase it and expect to sustain, in partnership with the city, meaningful hotel capacity with medical and behavioral health staffing in the future.

Lab preparedness

Over the course of the H+H response to covid19, the laboratories – under the leadership of Kenra Ford, SAVP for laboratories – we were able to test our patients and staff for COVID- 19 with turnaround times often ahead of those generally available. Early on, our labs brought COVID-9 PCR testing in-house. In addition, as soon as the FDA granted “emergency use approval” (EUA) of the rapid COVID-19 test, H+H was able to offer this to patients in our emergency rooms, on labor and delivery and wherever an immediate test result was needed.

And with the same swiftness, due to our early internal validation of the test system, H+H was able to offer the Abbott antibody test immediately after the FDA granted EUA approval of that test. Today, all 11 of our facilities are offering COVID-19 antibody testing to our health care workers.

In addition, our laboratories have registered H+H with the Mayo Clinic expanded access IRB approved “convalescent plasma as treatment” protocol.

The ability of H+H to offer not only timely staff and patient testing, as well as participation in a national clinical trial, requires not only capacity and competence, but foresight, diligence and preparedness.

Emergency Contracting

In order to accomplish this huge volume of work in a very limited amount of time, H+H has had to contract with critical external partners and vendors on an emergency basis. On March 1, 2020, NYC Health + Hospitals’ President issued a Declaration of Emergency, pursuant to which, the System is authorized to award contracts necessary to respond to the threatened spread of the virus without complying with the standard System’s Operating Procedure 100-5 or New York State General Municipal Law. Measures, reasonable under the circumstances, must be taken to ensure fair and competitive pricing and the selection of well qualified contractors free of any improper influence.

Under this authority and to meet emergency needs, the System has entered into a total of 68 new contracts to support the COVID-19 response effort. There have been a wide range of agreements made, ranging from agency staffing, hotels, medical equipment, pharmaceutical, telemedicine, and transportation. In addition, emergency purchase orders have been issued against existing contracts to obtain additional medical equipment and supplies needed in our hospitals as well as with new vendors, given the need to source scare supplies more broadly Further, the Office of Facilities Development has managed emergency construction in every one of our hospitals to increase bed capacity through task orders issued against existing contracts and through the award of several key new contracts.

Through April 27th, 2020, H+H has expended a total of $206.3M related to COVID-19. These expenditures included $125.8M for agency staffing, $11.1M for hotels, $36.8M for medical equipment, pharmaceuticals, supplies, and telemedicine, and $0.1M for transportation. Please note that there are additional purchasing commitments in these categories but payment have not yet been made.

Financials

To manage the spread of COVID-19, NYC Health + Hospitals took actions to prepare facilities for the anticipated increase in patients and reduce the need for non-COVID patients to come in-person to facilities. Per the Governor’s and Mayor’s mandate, we cancelled elective surgical procedures, contributing to an initial reduction in inpatient admissions of 12% compared to the baseline period prior to COVID. The reassignment of ambulatory care providers and staff to inpatient settings resulted in a decline in outpatient clinic volume of 48%, with approximately 1/3 of the remaining volume converted to telehealth.

As the COVID-19 crisis ramped up, inpatient admissions increased to more than 12% above the baseline, with COVID admissions making up 70% of all admissions. However, Emergency Department volume declined dramatically, despite the increase in admitted patients, driven by steep declines in treat and release visits. Estimated revenue follows these workload trends, with an initial dip of 13% in the beginning of the COVID period, followed by expected increases due to the higher volume and complexity of the COVID admissions. However, as COVID volumes begin to drop, we are anticipating that revenue could decline again until non-COVID workload rebounds and our system regulates. We are planning for that rebound across our system.

Concurrently, NYC Health + Hospitals has been proactively tracking the COVID-related expenditures and submitted a reimbursement claim to FEMA for $650M on March 27th. To-date, FEMA has conceptually approved $532M, and the system has spent over $200M on the following:

  • Contracted clinical and support staff ($200-300M estimated, $126M spent to-date)
  • Infrastructure and equipment ($200-300M estimated, $34M spent to-date)
  • Personal Protective Equipment (PPE) ($150-250M estimated, $38M spent to-date)
  • Lab testing ($100-150M estimated, $9M spent to-date)

To help combat the pandemic, Congress has passed multiple “stimulus” bills. The most direct financial support for healthcare providers was included in the Coronavirus Aid, Relief, and Economic Security Act (CARES) Act and in the bill referred to as Stimulus 3.5. In total, these bills created a $175B Provider Relief Fund. To date, $70.4B has been allocated. An additional to-be-determined portion is set aside for treatment of the uninsured; the remainder is still to be allocated. NYC Health + Hospitals received $117.7 million from the Provider Relief Fund to-date. Another relief bill, Stimulus 4, is expected in May. We believe that existing, unallocated funds and new funds should prioritize high-Medicaid and safety-net hospitals.

In this period, the SFY20-21 State budget was passed In this period, the SFY20-21 State budget was passed which included many of the recommendations proposed by the Medicaid Redesign Team (MRT) II panel. Based on pre-budget actions by the Executive and the enacted State budget, H+H estimates cuts of over $100M annually, most notably due to a 1.5% across-the-board rate reduction and reduction/elimination of quality pools and capital reimbursement. The final budget also included positive actions, including the acceptance of the MRT II proposal allowing for the UPL Conversion and Coordinated Care for Special Populations, as well as the increasing Indigent Care Pool equity (elimination of the transition collar). Given the uncertainties of the pandemic, the Governor was afforded additional superpowers to adjust the State budget during the year based on overall revenues. NYS released a report last week stating that they are projecting a $13.3B deficit for the current year.

Overall, NYC Health + Hospitals has approximately $400 Million (18 days) cash on hand at the end of April. To stabilize and ensure ongoing financial health, the system is seeking the following funding streams:

  • Bolstering regular patient revenue: $1B
  • Expediting State and Federal approval for owed Supplemental Medicaid payments: $800M
  • FEMA reimbursement advance for expenses to-date: $200M
  • CARES Act/Stimulus Funds: $ To Be Determined

Through these efforts, NYC Heath + Hospitals is focused on identifying revenue to offset the increased costs the system incurred related to COVID, as well as longer-term revenue streams to support us during the uncertain times ahead.

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WE ALWAYS PUT PATIENTS FIRST