Four lay‑offs and a reduction in over 500 hours of staff time per week have taken effect at Calais Regional Hospital (CRH) as a result of a deficit of over $500,000 in just the first two months of the 2014 year. Community Relations Director DeeDee Travis reports that, not including the four lay‑offs, 82 staff members have been affected by the cuts in hours, with those cuts felt in all departments. Of the 86 affected, 14 were in leadership positions.
"There were no targeted areas," she says. "We tried to do it as much as we could based on facts. We used national benchmarks on staffing requirements." Weekly hour reductions are divided between 233 clinical hours and 277 non‑clinical hours. Non‑clinical includes administration, says Travis. The hospital employs 264 people.
Vanessa Sylvester, representative for Local 116 of the Maine State Nurses Association, says the union has filed a grievance with the hospital for not following the protocol of the union contract. The union, which represents nurses and lab technicians, has approximately 80 members, and the grievance has been filed on behalf of 12 members. Sylvester, though, notes that everyone working at the hospital has been affected by the reduction in hours.
The reasons for the deficit are varied. Travis and CRH board Chair Everett Libby attribute some of the deficit to an increase in bad debt, changes in reimbursement rates, changes in Medicare rules and overall changes in the healthcare industry and laws, including unfunded mandates. Bad debt increased from $1,202,646 in 2012 to $1,982,274 in 2013. Amounts that were billed but not received from Medicare and Medicaid for services provided but for which payments are limited to a fixed amount rose from $16 million to almost $18 million in 2013.
However, the greatest cause for concern lies with how the residents in Washington County use the hospital, says Libby. Travis explains, "February bottomed out for us. We kept our assumptions modest with the budget." She adds, "We saw a big downturn in visits, and we don't know why." The downward trend has been slowly increasing, she explains. The hospital and the firm it uses for industry research and consulting services, Tennessee‑based Quorum Health Resources (QHR), have been aware of the trend for a while. "We had data showing we're outside of the norm of national benchmarks, with staff and volumes going down. Now we have to assume that down is the new norm." While she'd like nothing better than to see the new norm as up, "we have to staff to the level of patients."
Shirley Richardson of Eastport, an RN in the hospital's surgical unit, says every department at the hospital is being hit by a reduction in hours. While some employees are only minimally affected, losing perhaps an hour a week, others are being cut by half of their weekly hours. "Everyone in my unit has been cut," she notes, with the reduction in hours being equivalent to two full‑time staff members in a unit with only five people, including the supervisor. "It's been demoralizing for a lot of people."
"We will be doing an investigation of the practices of the hospital," Sylvester says, that will include examining the transfers of patients out of the hospital, the billing and spending practices, and the hospital's contract with Quorum. "Our priority is how to keep the services open to the patients in the community," she says. "The union doesn't believe these cuts are in the best interests of the patients in the community."
Union President Rebecca Lacasse says of Quorum, "I'm just not sure they're what we need for the community." Quorum charges $412,000 per year for its services in addition to salaries paid to two Quorum employees at the hospital, Chief Executive Officer Michael Lally and Chief Financial Officer Nancy Glidden.
Closure of two services
In addition to the staff hour reductions, two services have been shut down: the special care unit and pediatric admissions unit. However, Travis reiterates that the unit closures do not mean that children cannot be seen at the hospital or that surgeries cannot be performed. "We see a lot of kids, but they are mostly handled by the emergency department." She adds, "The emergency room is prepared to care for children of any age," and, if the child needs to be referred to a specialist, the physician "will initiate that call."
In 2013 the hospital had 9,696 emergency room visits, but the annual report number does not break down pediatric versus adult care numbers. The hospital had 66 births take place in the same year. A full roster of hospital department admissions and services can be viewed in the CRH annual reports, available on the website at <www.calaishospital.org>.
Closing the special pediatric admission unit means that specialty equipment and supplies sized for children that were rarely used and had to be thrown out after expiration dates are now costs that can be taken out of the budget, explains Travis.
The same holds true, Travis says, for the special care unit, which in 2013 was used by 3% of the total patient load. Both units had "been on the slide," she notes. Lacasse questions the usefulness of the 3% figure, explaining that it does not include the number of patients who could have been admitted but were transferred to a different hospital because of lack of staffing. The transfer number has "doubled or tripled" depending on the month, she says. She recounts that as a nurse in the ER she recently saw three patients transferred to a larger hospital because of lack of staffing. "That's hard for families," she adds, because of extra costs for transportation, family travel, meals and lodging, as well as the time involved.
Richardson has concerns about the implications of closing the special care unit. "It hamstrings the surgeons," she says, since surgeons will have to consider whether to perform a surgery if intensive care may be needed afterward. She notes that a hospital will not want to transfer a patient to another hospital after surgery, both because of the risk to the patient and the cost involved.
Travis states, "Special care has not been utilized in that fashion while the service was available. This is an issue that the surgeons have always had to consider because we are a small, rural hospital with limited resources for caring for special care patients. Even when we were accepting special care patients, the surgeons had to consider the patient's co‑morbidities and other risk factors for complications during or after surgery. If they felt a patient had great potential to need intensive care after surgery, the patient was referred to another facility for the procedure. Neither in the past nor currently would the surgeons keep a patient anticipating the need for that level of care." In 2013 CRH had 916 surgery cases.
Figuring out how to match the hospital's services with what the community needs and wants will be the continued work of hospital staff. In addition, efficiencies have been gained with propane conversion for the heating system, quality improvement efforts and the efforts of each department to look at expenses, says Travis. Patient care is the top priority, she adds. "We have the services and the staff. I can't say enough about the staff. They provide great care, great service. There's no other place I'd rather be, as an employee and as a patient."
Lacasse couldn't agree more about patient care being the top priority. From the perspective of the union, she says, cutting units and staffing is a patient safety issue. "We want Calais Regional to be the best rural hospital. It serves our families, our friends, every day."
The future of the hospital rests with how the community utilizes the resource, repeats Libby, and he has a tip for patients who receive specialized care at larger hospitals, such as those in the Bangor area. When lab tests and X‑rays are ordered, patients can insist that lab tests and X‑rays be done closer to home at CRH. "They don't have to have those things done there," Libby says. "I can understand why they [other hospitals] do it. Every hospital in the state is having trouble." In 2013 CRH performed almost 255,000 lab procedures, 13,859 radiology exams, 737 MRI exams and 2,289 CT scans.
Sylvester says that the union has sent a letter to the CRH board to meet and discuss concerns further. After union representatives met with CRH management the week of April 14, Sylvester reports that the union remains unconvinced that the cuts are in the best interest of the community. CRH Director of Human Resources and Compliance Kristi Saunders states, "It would be inappropriate to comment at this time, since the hospital's discussions with the union have not concluded."
Lacasse notes that the union has received a 21‑day notice from the hospital management of three potential lay‑offs in May. "The operating room and inpatient unit are being down‑staffed daily," she adds. "They're losing a lot of hours."
The Local 116 of the Maine State Nurses Association will hold a candlelight vigil on Wednesday, April 30, from 6 to 8 p.m. at the Triangle Park in downtown Calais. "This is the strongest I've ever seen the union," Lacasse says. "We've really come together and supported each other. It's nice to see. We're doing it because we feel strongly that the cuts wouldn't benefit the community."