As the COVID-19 patient census continues to decline, NYC Health +Hospitals has entered the phase of recovery and resilience. We are prepared to open up our operating rooms in accordance with State guidance, bring patients back for necessary ambulatory care services, and care for patients who need chronic ventilator support.
Bringing back the ORs: The periop leads have been working diligently to bring back the procedural areas including the operating rooms, as these areas, which include the ASU and PACU’s, are no longer needed as flex ICU spaces as the COVID-19 census declines. A “roadmap” has been developed to facilitate the return of the OR’s. More than 9,000 surgical cases are waiting to be performed. The State has explicitly confirmed that hospitals can and should continue to provide emergency and essential procedures and surgeries, such as those for diagnosis of cancer, treatment of intractable pain, and other services for highly symptomatic patients. H+H is following this guidance. These cases have been prioritized based on disease classification and number of previous hospital admissions, sent to each surgery chief in our health system, who have subsequently re-scheduled these cases according to acuity. Each patient will be COVID-19 tested within 72 hours of the date of service. Ambulatory care COVID-19 capacity was established to provide same day access. Specific operation rooms have been designated for COVID-19 positive patients and COVID-19 negative patients. System wide PPE protocols have been developed for surgical cases and a systemwide policy has been developed governing performance of scheduled procedures in the context of the Governor’s executive order.
Emergency Rooms: Re-envisioning the post-COVID, pre-vaccine NYC Health + Hospitals Emergency Departments are working in collaboration with Office of Facilities Development, EITS and Supply Chain to ensure clean ED’s that are safe for patients to seek medical care without fear of contracting COVID-19.
Tele-ICUs: As the number of patients requiring critical care exceeded the number of critical care beds and intensivists, tele ICU became a viable option – to provide critical care support for ICU patients in atypical locations and / or managed by non-intensivists. We initiated two pilots of tele-ICU: one at Bellevue and one at Jacobi. Communication was predominantly via telephone, though video conferencing was available via a laptop and webcam. The feedback was very positive. The conclusions drawn from these pilots was that tele-ICU can indeed provide viable critical care coverage. We are currently pursuing this to understand the scale of our need, financial and technological investments needed.
Long Term Acute Care Hospitals: Under the physician leadership of Drs. Margolis and Boudourakis, our LTAC facilities have begun accepting appropriate transfers from our acute care ICU patients which allows our acute care ICU’s to return to their pre-COVID-19 census, and capacity. Between 5/11 and 5/21, 48 ICU transfers have been admitted to the LTACH. The goal is to transfer to the LTACH those ICU patients currently on med surg units in our acute care facilities who are appropriate for an LTACH level of care. For the most part these are patients who are chronic ventilator patients no longer requiring critical care.
Blood Supply: On May 15th, the New York Blood Center reported a shortage of blood products, driven by reduced donations during the COVID-19 shelter in place restrictions. We immediately began monitoring our blood supply system wide, including twice daily touch points with the system CMO, Trauma and Peri-op leads. We also worked with City Hall to publicize this concern and encourage blood donation. We were able to successfully import blood from a secondary blood supplier which enabled all H+H blood banks to return to target inventory levels by May 21. The system will continue to monitor as the NYBC returns to routine blood supply levels.
Helping Healers Heal (H3): Emotional and psychological support of our health care heroes continues through H3, Behavioral Health services, and a new collaboration with Department of Defense to combat stress management and resilience. Our heroes were there for New Yorkers during the COVID-19 surge, we need to be there for them now. Our philanthropy efforts have raised so far over $26 million, as we continue to provide comfort care to our frontline staff.
Test & Trace Corps
The COVID-19 Test & Trace Corps is charged with testing New Yorkers for COVID-19, tracing to identify contacts who may have been exposed to the virus, and then connecting them to either wrap around support services at home or a hotel if they cannot safely isolate at home. Under the leadership of the Corps, New York City will be completing more than 20,000 diagnostic tests each day the week of May 25, a metric the City reached a week early. And this week we announced that more than a dozen new testing sites will open next month. By early June, the Corps will have 2,500 tracers doing this important work for New Yorkers and has 1,700 new tracers ready to start on June 1st — many of whom represent some of the hardest hit communities and speak nearly 40 languages.
We have launched a new pubic website www.nychealthandhospitals.org/testandtrace and a $10M multi-lingual advertising and outreach campaign. The Mayor also appointed the program’s new Chief Equity Officer who will support the Test & Trace Corps effort to address racial disparities and engage communities that have been disproportionately affected by the virus.
NYC Health + Hospitals/Coler
The New York State Department of Health conducted a standard COVID-19 survey at NYC Health + Hospitals/Coler from May 18 – 19, 2020. The survey team consisted of 8 surveyors on-site and 1 off-site. This is a standard survey that NYS Department of Health is conducting at nursing facilities throughout the State to assess the level of compliance with all NYS DOH guidelines related to COVID-19. At the conclusion of the 2-day survey, Coler was informed that the information provided to and gathered by the surveyors would be reviewed by the home office before any determinations or findings were made. No immediate corrective actions were required by the survey team while on-site during the survey.
The focus of this standard survey was on infection control practices, PPE supplies and usage, staff education, resident and family communication, and COVID-19 related deaths. The surveyors reviewed the facility practice of cohorting COVID-19 positive residents together in the same room. They also reviewed the practice of cohorting f presumed positive residents together in the same room.
The NYS Attorney General’s Office – Medicaid Fraud Unit is also in the process of conducting an off-site COVID-19 review of Coler. These reviews are being conducted by this agency of nursing homes throughout the state. The telephone interviews and informational request focused on infection control practices, PPE usage and supplies, resident and staff testing, staffing levels, and resident deaths related to COVID-19. Information related to the environmental services and pest control programs was also requested, which seems to be related to the New York Post article.
Coler leadership continues to work collaboratively with other community stakeholders, including its Community Advisory Board, local advocates, and elected officials.
Pilot Visitation Program
Limiting visitation to protect patients, visitors, and staff during the COVID-19 surge was one of the most heart wrenching consequences of the pandemic. We are excited to participate in the NYS hospital visitation pilot with NYC Health + Hospitals/Jacobi, NYC Health + Hospitals/North Central Bronx and NYC Health + Hospital/Coney Island being our first three sites to allow family to visit patients in our hospitals while taking all precautions to keep everyone safe. The pilot will last for 2 weeks and started on May 26th. We hope this pilot will lead to expansion of visitation across our system to reconnect patients with loved ones.
COVID-19 Surge and Post-COVID-19 Revitalization
As reported at the Finance Committee on May 14th, in preparation of the COVID surge, H+H took actions to prepare facilities for an increase in COVID-positive patients and took steps to reduce the need for non-COVID patients to be seen in-person, including with the cancellation of elective surgeries. The result was declines of 42% in outpatient visits and 12% in inpatient admissions compared to the pre-COVID baseline. This resulted in an initial revenue decline of 13%. However, with the onset of the COVID surge, the volume and complexity of cases increased. The result was a near breakeven in revenue between the pre-COVID and COVID surge period. Subsequently, as COVID admissions have declined, there has not yet been a return of non-COVID admissions, causing a net 14% decline in the post-COVID surge period. Despite this, the system’s cash position has remained steady and is expected to close May with approximately $400M cash on hand (18 days).
Additionally, to recapture the lost revenue and continue to stabilize the system in the post-COVID period, the system has begun a re-envisioning of the system with a sustained focus on ambulatory and perioperative care. These strategies will ensure that the system is prepared for dealing with the uncertain healthcare and fiscal landscape caused by COVID.
Federal Relief – FEMA/HHS
NYC Health + Hospitals has been proactively tracking the COVID-related expenditures and submitted an initial reimbursement claim to FEMA for $650M on March 27th. Due to the expedited submission, we quickly received approval from FEMA for $532M. The system is currently waiting to receive an advance of these funds of over $200M.
Subsequently, the system has also revised its initial COVID-related cost estimates upward to $1.1B to reflect the expanded scope that the system was asked to take on during the COVID surge. The major adjustments included an increase in infrastructure costs due to buildout of the surge capacity space at the Billie Jean King Tennis Center and Brooklyn Cruise Terminal. The system was also required to increase its contracted staffing commitments for nursing and respiratory therapists due to greater levels of staff absences and higher patient volume. Lastly, the system expects greater PPE-related expenditures related to the Governor’s directives regarding stockpiles and minimum standards for supplies.
In addition, the system has been advocating for and receiving federal relief from the multiple “stimulus” bills passed by Congress, most notably the CARES Act and Stimulus 3.5. These bills provided direct financial support to healthcare providers through the creation of the $175B Provider Relief Fund. To date, $72.4B 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 has received $832M in COVID-related funds to-date largely from the Provider Relief Fund general and high-impact (hot-zone) allocations. We continue to advocate that existing, unallocated funds and new funds prioritize high-Medicaid and safety-net hospitals.
State Actions – MRT II Implementation and Timely Reimbursement
During the COVID pandemic, the State enacted its SFY20-21 budget, which included recommendations from the MRT II workgroup. These recommendations included our health system’s proposals regarding the UPL Conversion and Coordinated Care for Special Populations. Throughout this period, we have been working with our partners at DOB and DOH to implement these major initiatives. Additionally, we have been having ongoing conversations with the State regarding the $800M in pending supplemental Medicaid payments that the system is owed as well as seeking a settlement related to outstanding claims and outlier payments. These revenues are necessary for our public safety net system to continue to maintain its stable cash position.