Purpose: Demonstration
Submitted: November 18, 2010
Executive Summary
Description
New York Hospital Medical Center of Queens, a 439- bed not-for-profit hospital located in Queens County, requests approval to create a 16-bed Transitional Care Unit (TCU) to bridge the gap between the Hospital’s acute care and post-acute care settings. On September 1, 2010, the Department of Health requested applications in accordance with the
provisions of Section 2802-a of the Public Health Law for a TCU Demonstration Program.
The TCU will be designed to achieve the following objectives:
• Improve clinical outcomes for medically complex patients by providing 24-hour skilled nursing and rehabilitative care prior to long-term care or discharge home.
• Assist patients to fully recover before discharge. • Reduce overall patient length of stay.
• Educate and prepare family members for care for these patients at home.
The TCU program will provide access to rehabilitation therapies, which in turn will reduce the Hospital’s overall medical length of stay per TCU eligible patient. The TCU unit will be located on the seventh floor of the main hospital building. Management of the TCU unit, including staffing and training for the unit, will be provided by Silvercrest Center for Nursing and
Rehabilitation, a 320-bed residential health care facility (RHCF) that is a related entity of NYHQ.
Total project costs are estimated at $33,372.
DOH Recommendation
Contingent approval.
Need Summary
Section 2802-a of the Public Health Law was amended by Chapter 58 of 2010, authorizing the Commissioner to approve an additional 13 general hospitals to operate transitional care units (TCUs) on a demonstration basis.
Program Summary
The principal elements of the proposed TCU program are:
• 16-bed unit on the 7th
Floor, South Building • Single and Double-bedded Rooms
Financial Summary
Project costs will be met with accumulated funds of $33,372 from New York Hospital Medical Center of Queens.
Incremental Budget: Revenues: $ 2,797,827 Expenses: 2,197,576
Gain/(Loss): $ 600,251
The applicant has demonstrated the capability to proceed in a financially feasible manner, and approval is recommended.
Architectural Summary
This project involves the renovation of 5,700 SF of the eighth floor of the hospital for a 15-bed transitional care unit.
Recommendations
Health Systems Agency
There will be no HSA recommendation for this application.
Office of Health Systems Management Approval contingent upon:
1. Submission of a check for the amount enumerated in the approval letter, payable to the New York State
Department of Health. Public Health Law Section 2802.7 states that all construction applications requiring review by the Public Health and Health Planning Council shall pay an additional fee of fifty-five hundredths of one percent of the total capital value of the project, exclusive of CON fees. [PMU]
2. Indicating location of ADA Accessible toilet within the area of work, acceptable to the Department. [AER]
Approval conditional upon:
1. The submission of State Hospital Code (SHC) Drawings for review and approval, as described in BAEFP Drawing Submission Guidelines DSG-01. [AER]
2. The submission of Final Construction Documents, as described in BAEFP Drawing Submission Guidelines DSG- 01, prior to the applicant’s request for, and Department’s granting approval for the start of construction. [AER] 3. The applicant shall complete construction by August 31, 2013. In accordance with 10 NYCRR Part 710.2(b)(5)
and 710.10(a), if construction is not completed on or before that date, this may constitute abandonment of the approval and this approval shall be deemed cancelled, withdrawn and annulled without further action by the Commissioner. [AER]
Council Action Date August 4, 2011.
Need Analysis
Background
Section 2802-a of the Public Health Law was amended by Chapter 58 of 2010 authorizing the Commissioner to approve an additional 13 general hospitals to operate transitional care units (TCUs) on a demonstration basis. The original TCU enabling legislation of 2005 authorized five demonstration projects.
Transitional Care Unit Purpose
Section 2802-a of PHL defines "transitional care" as sub-acute care services provided to inpatients of a general hospital who no longer require acute care inpatient services, but continue to need specialized medical, nursing and other hospital ancillary services and are not yet ready for discharge. TCUs should be limited in length of stay and designed to meet and resolve patients' specific sub-acute medical care needs. Discharges from these units are to be timely and appropriate.
The improvement of quality outcomes for the TCU population through the provision of appropriate services, delivered in the most efficient manner, is the primary goal of the TCU demonstration program. Hospitals selected for this
program are required to demonstrate an overall decrease in length of stay, quantify the clinical benefits of the program for TCU patients, and illustrate a synergistic relationship with long term care providers in the community. Collaboration between hospitals and nursing homes in local service areas will help bring about more efficient allocation of patients between the two settings.
In accordance with Section 2802-a of PHL, all providers applying to participate in this demonstration program must meet all Conditions of Participation (CoP) for skilled nursing facilities (SNFs) as defined under Title XVIII of the Federal Social Security Act (Medicare). In order to qualify for Medicare certification, providers must comply with Part 415 of Title 10 of the New York Compilation of Codes, Rules and Regulations (10 NYCRR). In this demonstration, providers not currently licensed to operate nursing home beds will not be required to obtain Public Health and Health Planning Council establishment approval. Additionally, TCU units are not recognized as RHCF beds as defined in 10 NYCRR Section 709.3.
As part of this demonstration program, specific State SNF regulations that may impede the development of TCUs or their ability to provide appropriate services to patients may be subject to waiver, at the discretion of the Department. Such issues will be reviewed on an individual basis.
Applicants must demonstrate the need for any services proposed within the TCU and emphasize the benefits of such a program to a specific community, including, but not limited to, addressing the absence of sufficient post-discharge services in nursing homes and community-based care.
Transitional care units should be limited in length of stay and designed to meet and resolve specific sub-acute medical care needs. The average length of stay for patients served in a TCU ranges from 5 to 21 days, following a qualifying acute care stay. TCU services will be reimbursed at the applicable Medicare per diem SNF rate.
Transitional Care Unit Criteria and Requirements
Section 2802-a requires all providers applying to participate in this demonstration program to meet all applicable requirements as defined under Title XVIII of the Federal Social Security Act (Medicare). Additionally, Transitional Care Units must:
• Have a length of stay of not less than 5 days and not in excess of 21 days; • Have a pre-opening survey, separate Medicare Number, and SNF certification; • Be staffed by qualified staff dedicated to the TCU;
• Serve patients who will benefit from active rehabilitation. (It is expected that patients will actively participate in three hours or more of Occupational Therapy/Physical Therapy/Speech Therapy, every day, either three hours consecutively or in combination between rehabilitative sessions); and
• Collect information and submit reports to the Department on an annual basis to demonstrate an overall decrease in length of stay; quantify the clinical benefits of the program for TCU residents and illustrate a synergistic relationship with long term care providers.
Applications must address the configuration of the Transitional Care Unit. However, the applicant must adhere to the following requirements:
• Beds must be located at one geographic location; and
• Beds must be located contiguously within a distinct unit/space within the hospital.
Recommendation
From a need perspective, approval is recommended.
Programmatic Analysis
Background
The TCU will focus on patients who, if not discharged to the TCU, would continue to be served in a Med/Surg bed. These patients will remain in the TCU for a short stay of 5 to 20 days. The applicant projects an average length of stay of approximately 20 days during the first year of operation, decreasing to 16 days by the fifth year.
The TCU will focus on patients with congestive heart failure, myocardial infarction, or pneumonia, who are de- conditioned and require additional days of rehabilitation and/or monitoring before discharge.
Management of the TCU, including staffing and training for the unit, will be provided by Silvercrest Center for Nursing and Rehabilitation, a 320-bed RHCF that is affiliated with New York Hospital Medical Center of Queens (NYHMCQ). The TCU’s management team will consist of a Medical Director, a director of nursing and a licensed nursing home administrator. The TCU will use an interdisciplinary care team approach consisting of physicians, psychologists, care managers, nurses, physical therapists, recreational therapists, occupational therapists, respiratory therapists,
speech/language pathologists and dieticians.
New York Hospital Medical Center of Queens is a member of the New York-Presbyterian Healthcare System. The applicant will enter into a Memorandum of Understanding with Silvercrest Center for Nursing and Rehabilitation to ensure that patients who are cared for by the TCU have nursing home services available to them upon discharge. On a quarterly basis, the substantive results of the quality review program will be reported to NYHMCQ’s quality committee and ultimately to the Board of Trustees. That reporting will also be submitted to the Department of Health to assist in the monitoring of the TCU Demonstration Program.
Recommendation
From a programmatic perspective, approval is recommended.
Financial Analysis
Total Project Cost and Financing
Total project cost for the acquisition of moveable equipment is estimated at $33,372, itemized as follows: Moveable Equipment 10,400
Telecommunications 20,800
CON Fee 2,000
Additional Processing Fee 172 Total Project Cost $33,372
Operating Budget
The applicant has submitted an incremental operating budget, in 2011 dollars, for the first and third years, summarized below:
Year One Year Three
Revenues $2,485,289 $2,797,827
Expenses:
Operating $2,048,999 $2,192,576
Capital 5,000 5,000
Total Expenses $2,053,999 $2,197,576 Excess of Revenues over Expenses $431,290 $600,251 Utilization: (patient days) 4,745 5,110
Occupancy 81.25% 87.50%
Utilization for the first and third years is 100% Medicare.
Expense and utilization assumptions are based on the historical experience of New York Hospital Medical Center’s inpatients.
Capability and Feasibility
Project costs of $33,372 will be satisfied by accumulated funds from New York Hospital Medical Center of Queens, which indicates the availability of sufficient funds as presented on Attachment A.
The submitted budget indicates an excess of revenues over expenses of $431,290 and $600,251 during the first and third years, respectively. The budget appears reasonable. The Medicare revenues are based on RUG rates for Medicare in selected RUGS categories, in which TCU patients are expected, and were used to calculate
reimbursement rates.
As shown on Attachment A, the hospital maintained an average positive working capital position and an average positive net asset position during the period shown. The hospital achieved an operating excess of revenues over expenses of $4,806,000 and $12,313,000 during the 2009 and 2010, respectively.
Presented as BFA Attachment B are the May 31, 2011 internal financial statements of New York Hospital Medical Center of Queens. As shown on Attachment B, the hospital had a positive working capital position and a positive net asset position for the period through May 31, 2011. Also, the facility achieved an operating income of $570,000 for the period through May 31, 2011.
The applicant has demonstrated the capability to proceed in a financially feasible manner and approval is recommended.
Recommendation
From a financial perspective, approval is recommended.
Architectural Analysis
Background
This project will consist of 5,700 SF of renovation of the eighth floor of the hospital and will include 15 transitional care beds, 13 private patient beds and 2 semi-private patient beds. Also included are a rehabilitation gym, offices, a nurse station, medication room, clean and soiled utility rooms and a staff toilet room.
Environmental Review
The Department has deemed this project to be a TYPE II Action and will not have a significant effect on the
environment. An Environmental Impact Statement is not required. However, any agency that has an interest in this project may make their own independent determination of significance and necessity for an EIS in accordance with the procedures specified within Part 97.8 of Title 10: Rules and Regulations.
Recommendation
From an architectural perspective, approval is recommended.
Attachments
BFA Attachment A Financial Summary- 2009 and 2010 certified financial statements of New York Hospital Medical Center of Queens
BFA Attachment B Financial Summary- May 31, 2011 Internal Financial Statements of New York Hospital Medical Center of Queens